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					APPROVED May 13, 2008
                                               GACHA Council Meeting
                                                  Red Lion Hotel SeaTac
                                                      March 11, 2008


Members Present:                      Members Excused:                    Ex-Officio Members:
Becky Mares                           Susan Fabrikant, MSW                Rep. Jeannie Darneille
Michael McCoy                         Judith Billings, JD                 (absent)
Mendy Droke                           John Valliant
Lara Strick, MD, MS,                  Mark Garrett                        Others Present:
DTMH                                  Lance Kissler                       Cathy Cochran, DSHS/HRSA
Darlene McLeod                                                            Cathy Fisher, DSHS/HRSA
David Lee, MSW, MPH,                  Members Unexcused:                  Mark Westenhaver,
LICSW                                 Rev. Mary Diggs-Hobson              DSHS/HRSA
Jeff Schouten, MD, JD                 Robert Carroll, PhD(c), RN,         Nikki Behner, Snohomish
Charles Emlet, Ph.D, MSW              ACRN                                County
Bob Harrington, MD                                                        Sandy Needham, Snohomish
Tim Hillard                           Staff Present:                      County
Wendy Doescher                        John Peppert                        Alex Whitehouse, Region 3
Bob Wood, MD                          Richard Aleshire                    Coordinator
Pam Tollefsen, RN, M.Ed               Tracy Mikesell                      Gail Howard, LLAA (by
Steven Wakefield                      Karen Robinson                      telephone)
Robert Gunstrom                       Lynn Johnigk                        Shayne Glessing-Karzmar
                                                                          Ian Karzmar


The meeting was called to order at 9:15 a.m. by Chair Jeff Schouten.
Self-introductions were given.
The agenda was reviewed. No changes were made.

Minutes
December 14, 2007
It was moved by McCoy to accept the minutes as printed. Seconded by Doescher. Passed
as printed.

Membership – Jeff Schouten
Appointments for 5 Council members expire on June 30, 2008: Billings; Doescher; Hillard;
Valliant; and Wakefield. Members interested in reapplying for Council appointment should
contact the Department of Health, Infectious Disease and Reproductive Health.

Chair Report – Jeff Schouten
The AIDS Clinical Trial Group leadership retreat was held March 3 – 6 in Denver. Fairly large
naïve trials have been held in past years. Currently there isn’t a naïve trial and support for a
naïve trial was pulled back by the sponsor. Of thirty-one randomized prevention trials to date,
only four have been positive and three of the four related to circumcision.

Per Wakefield, the challenge is to reach women at risk exists for both the vaccine and prevention
network. Social networking is being used to address the challenge.

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Vice Chair Report – David Lee
The following trainings have been conducted.
March 8 in Olympia – HIV and Corrections: approximately 50 providers attended and heard
information on HCV, HIV, opportunistic infections, and STDs. Providers from county jails and
a federal facility in addition to state correctional facilities attended. Two speakers were from
California. This is an annual conference. This training will be given in Salem, Oregon in April.

March 3 and 4 in Bellingham - HIV Update and recognizing opportunistic infections

March 12 in Omak – HIV Update: around 50 providers are expected to attend

Schouten mentioned the American Academy of HIV Medicine AAHIVM has revised their
credentialing requirements for rural providers. A rural provider can be credentialed as an HIV
specialist if they have a one-on-one mentoring relationship with another credentialed HIV
physician. This is modeled after the University of Washington’s medical consult service. The
academy is allowing pharmacists (pilot program) to take the exam this year. If there is enough
interest shown, an exam specifically for pharmacists will be developed. Harrington reported
Harborview has an HIV track in their internal medicine residency training with 1 intern involved.

CAREvent 2007 Perspectives
Members attending the conference made the following comments.
 Great conference, many tracks for infected, affected, and service providers
 Good informational tracks
 Convenient place
 Happy to see the conference again
 Big success
 Broad and interesting
 Some attendees seemed naïve regarding HIV
 Very informative
 Learned of others in his community that are positive
 Opening speaker was incredible

Evaluations were done for each plenary and breakout session held. Richard Aleshire detailed the
results of the evaluations.
Each speaker received a score in the upper 8s to mid 9s out of 10.
 Glen Treisman – Johns Hopkins
 Julie Scofield – National Alliance of State and Territorial AIDS Directors
 Jim Pickett – Chicago AIDS Foundation
 Charles King - Housing Works
 Martin Delaney – Project Inform

There were 48 breakout sessions with each receiving high marks as well.
The comments on the pre-conference for consumers were good.




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Department of Social and Health Services – Cathy Cochran, Department of Social and
Health Services; Cathy Fisher, Health and Recovery Services Administration; and Mark
Westenhaver, Economic Services
Categorically needy (some programs are mandatory (required by federal government), some are
optional)
 Must be over age of 65, blind, or disabled to qualify.
 The goal is to cover as many individuals as possible.
 Categorically needy is a group of individuals with very low income - $637 per person.

Medically needy (optional programs)
 Must be over age of 65, blind, or disabled to qualify and is the largest group served
 Not all services are provided
 These programs include spenddown
 Must meet general eligibility requirements
       Assets (IRAs, investments money, bank accounts, life policies with cash value, etc)
          below $2,000 for single and $3,000 for a married couple. No upper cap for income –
          just increases spenddown.
 Program for nursing home clients – assets can be spent down to qualify. Hospice care for
  patients with income of $1,911 or less is available
 Children with income at 250 percent federal poverty level (FPL) are covered also – premium
  based program between 200 – 250 percent FPL. The FPL goes up on April 1, 2008 to 300
  percent.
 Pregnant women covered at 185 percent of the FPL.
 Spenddown is calculated on monthly income that is over the standard ($637 for 1 and 2
  people) – can be met by incurring expenses.

MN-SSI Related Income Disregards
 $20 – unearned income
 $65 and ½ of the balance – earned income
 Child care (allowed if client is working)
 Child support paid is not allowed

Setting a Base Period
 Federal guidelines mandate certification every 6 months. –some states have clients recertify
    monthly. A base period of 3 months can be requested.
 Clients are allowed to meet 3 month spenddown – bills for previous 3 months are reviewed.

What can be used to meet spenddown?
 Prior unpaid medical expenses still owed by the client or their family members
 Medical expenses incurred by the individual or their family members residing in their
  household (minus any 3rd party liability) during the base period whether paid or unpaid.
 Expenses not covered by the medically needy program.
 Transportation expenses to medical appointments.
 Medical expenses potentially payable by Medicaid which the client incurs in the current base
  period even if claim would not be paid because it exceeds HRSA limitations on amounts,
  duration or scope of services.



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Additional Information
 There are 3-4,000 participants in the medically needy program at any 1 time.
 Standard of promptness (timelines) in processing applications is as follows:
        30 days – the majority of applications
        45 days – for medical applications
        Longer (60 days) for disability determination applications through Disability
          Determination Services
 All documents received now are electronically scanned and sent to the desktop of a case
  manager (done within 24 hours of receipt).
 One-time verification of citizenship (applicant signs a declaration of citizenship) – DSHS
  orders birth certificate for out-of-state births. Washington births are verified through the
  Department of Health.
 There is a 45 day notice to clients regarding closure of 6 month base period.
 Reapplication is mandatory for medically needy programs for each base period.
 Clients are encouraged to apply when they begin incurring expenses.
 Request for retroactive review of application for previous 3 months can be made.

Early Intervention Program
 Clients reauthorized annually – the feds are pushing for six month reauthorization.
 Coordinates annual reapplication with DSHS semi annual base periods.
 Notice of renewal goes out 45 days in advance of renewal.
 DOH has full access to DSHS’s ACES - Automated Client Eligibility System, but DSHS
   does not have access to DOH’s database.
 70 EIP clients are in spenddown – case managers are notified of renewals and work with the
   DSHS case manager.

Final Comments and Thoughts
 Case management services are very important.
 Would it be helpful to know the percentage of people who have trouble getting meds and
   why? Are system failures monitored – it is felt that a very small percentage of clients go
   without services/medications
 There was a 25% reduction of clients due Medicare Part D.
 Cathy Fisher provided her phone number and let people know she could be contacted if
   questions arise

Introduction of Karen Robinson – Richard Aleshire
Karen Robinson was introduced. She began working for HIV Client Services October 16 and
oversees case management and community services. She came from the Johnson County Health
Department in Iowa State.

2008 Workplan
The dates for 2008 meetings were reviewed. It will be determined later if a full Council meeting
will be held in August. The November 11 meeting is on Veteran’s Day. It was decided to have
the meeting on November 18. The following suggestions for meeting topics or presentations
were made.
 Housing for people living with AIDS
 Inmates panel/public defenders – care and treatment in jails and prisons - May
 HIV routine testing – guidelines; implementation; costs; resources

                                                4
   Prevention efforts in schools – speakers bureau
   Curriculum implementation; overview of public information in schools – September
   Communities of faith around HIV treatment and prevention
   Forum outside Seattle
   Grants – loss of funding; technical assistance; management of funds/paperwork
   Provision of care statewide – workforce issues; infrastructure
   Data on foreign-born blacks outside King County
   Review of Council Structures and Procedures
   HIV testing of infants going into foster care
   PEP (post exposure prophylaxis)/PREP (preexposure prophylaxis) – access in rural areas
   Lifelong AIDS Alliance (LLAA) Medical Nutrition Program
   Elections - November

Board of Pharmacy Case – Jeff Schouten
A restraining order remains effective statewide regarding the filling of orders by pharmacists.
Trial stayed while the case goes to the Court of Appeals. The DOH cannot enforce the rule. The
case went to the Court of Appeals on February 29. Both the appeals and the trial are moving
forward simultaneously. It could be a year before a decision is made.

AIDSNET Report – Wendy Doescher
Three white papers were developed by the AIDSNET Council regarding changes to WAC. The
papers were presented to the Washington State Association of Local Public Health Officers
(WSALPHO) on March 4.
1. Bring codes in line with standard testing procedures – remove any barriers and get ride of
exceptions – WSALPHO accepted with small changes per Peppert
2. Address partner counseling and referral services – remove permission from primary care
provider (gate keeper) – WSALPHO fully endorsed per Peppert
3. Incidence and resistance surveillance – have confirmatory testing consolidated into 1 or 2 labs
statewide – WSALPHO rejected per Peppert
The papers were submitted to the Public Health Executive Leadership Forum (PHELF) which
agreed with the decisions WSALPHO made. Peppert will present the recommendations to Mary
Selecky prior to submission to the State Board of Health. The papers will be made available to
GACHA members.

Work on performance measures for Council being discussed and formulated.

Regions are waiting for their notice of Ryan White funding allocation.

Lunch Presentation: Snohomish County Corrections: The Handling of Inmates with HIV
Nikki Behner, ARNP, MN, MPH; Sandy Needham
Snohomish County Corrections (SCC) is an Executive Department within the Snohomish County
Government: operates the Snohomish County Jail and the Center for Incarceration Options and
Alternatives.
SCC provides detention services and offender program services to:
 Snohomish County Superior Court
 Snohomish County District Courts
 Snohomish County Sheriff and other Law Enforcement
 Nineteen municipalities
 Washington State Department of Corrections (community custody violators)
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 Tulalip Tribes
 Citizens of Snohomish County
 Inmates and inmate’s families
The fees collected provide a source of revenue: $89 per booking and $58 per day
Between the two jail facilities, between 1,200 and 1,300 inmates are housed on a daily basis.
Jail Health Services (6 mental health professionals; 14 RNs; ARNP; dentists, and a number of
physicians) consist of the following:
 An urgent care level of service
 24 hour nursing presence
 24 hour medication accessibility
 Licensed mental health practitioners
 Professional medical staff
 Psychiatrist and dental appointments
 Medical booking screening
 Certified professional health services staff
 Coordinated care with outside health care
 Transition services for “special needs” populations including “jail transition services”
 Durable medical equipment available
 Detox monitoring under medical supervision
 Medical housing unit for close observation
 Opiate substitution program.
Offender Change Programs consist of offender change; alcohol and drug treatment; offense
related; life skills; academic; religious; and employment.

Population Profile
       2000                                        2007
19,103 bookings                             23,776 bookings
  65% misdemeanor                             58% misdemeanor
    17% alcohol-traffic                         25% alcohol-traffic
    22% non-alcohol traffic                     22% drugs
   13% drugs                                    12% on-alcohol traffic
     6% domestic violence                       15% domestic violence

  35% felony                                   42% felony
   34% other (parole violation)                 37% Other (parole violation)
   35% non-violent                              30% non-violent

Male          81%                                  79%
Female        19%                                  21%
White         83%                                  77%
Black          7%                                   9%
Hispanic       4%                                   6%
Other          6%                                   9%

18-24         22%                                  24%
25-34         33%                                  31%
25-44         31%                                  28%
45+           13%                                  16%

                                               6
Length of Stay Statistics                        % of Bookings
   0 – 3 days                                       53%
   4 – 10 days                                      14%
  11 – 30 days                                      19%
  31 – 60 days                                        8%
  61 – 90 days                                        3%
  91 – 180 days                                       3%
 181 + days                                          .5%

Seventy-five percent of the males and 70% of the females booked into the SCC test positive for
the use of illicit substances including marijuana, crack or powder cocaine, opiates including
heroin, and methamphetamine. The number of arrestees dependent upon drugs has continually
increased over the last four years. Two specific treatment programs were introduced in 2005 to
address the increasing chemical dependency and abuse among the incarcerated.

Mental health issues continue to be another challenge. Approximately 5 (50 – 55) percent of the
population have severe mental health problems that require special housing and special care.
Another 2 or 3 percent (28) are being treated for mental health but do not require special housing
and another 45 are housed in a psychiatric step-down unit.

Medications are provided if needed to inmates. If an inmate has money on the books, a small co-
pay for any medication provided will be taken. Other appointments and any labs are covered by
SCC and, in some cases, DSHS will cover during the month coupons are current. Other services
provided for free are haircuts, library services, food, hygiene products, and writing materials.

 Approximately 8 individuals per month are in SCC who are known to be HIV positive.
 Outside services are sought for inmates when necessary and cannot be provided by SCC
  providers.
 Patients routinely are released with 3 days worth of medications – no benzos or narcotics.

The case study of a couple of arrestees were reviewed.

The complete presentation is available upon request.

15th Conference on Retrovirus and Opportunistic Infections – Jeff Schouten, Steven
Wakefield, David Lee
The conference originally focused on United State based hard core laboratory and basic science
treatments but has become an international conference with international focus including
information on vaccines and prevention activities.

Interesting presententations:
AIDS Clinical Trials Group study – when to start retroviral therapy in people with opportunistic
infections
 Participants were never on HAART or not on for last 6 months (TB not included).
 The group starting therapy early did much better: lower rate of death and fewer opportunistic
    infections in first 6 months.
 At 48 months the benefits were the same for both groups.



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Treatment trial
 Trial groups for new drugs: dirunavir; maroviroc; raltegravir
 At 24 weeks the viral suppression was 50 – 60%.
 The suppression was maintained at 48 weeks.
 With the second wave of HAART, people are getting undetectable.

Intermittent therapy study – presented in 2007 Smart Study
 Intermittent therapies were done because of cost effectiveness and less toxicity
 Finding was that there was a higher rate of complications more frequently (heart disease,
    liver, kidney disease)
 5,500 person study – stopped early because of the higher rate of complications
 Follow-up at this conference to explain why intermittent therapy is not good

There are a couple studies around when to start therapy. Starting early still seems the best
treatment with better outcomes. The National Institute of Health (NIH) attempting to find
volunteers for this type of study.

A survival study – higher mortality rate when second regimen fails. Mortality rates are
unchanged compared to 5 to 10 years ago.

Prevention Activities
 Herpes outbreaks – will it reduce HIV transmission?
 Study involved women in Zimbabwe, Zambia and South Africa who were HIV negative and
   HSV2 positive and gay men in the US and Peru.
 Participants were provided with acyclovir twice daily. There was no difference in the
   acquisition for the 2 groups.
 The study was disappointing.

Circumcision – implementing globally
 Information presented from an on-going study showed women at greater risk of acquisition if
    the man is circumcised as an adult.
 In the US, the American Pediatric Association is considering recommending circumcision at
    birth.
 Difference shown for STDs in individuals who were circumcised vs those not circumcised.

Post Exposure Prophylaxis (PEP) and PreExposure Prophylaxis (PREP)
 Small studies in Peru and South Africa (possibly others) looking at PREP. Meds given on a
   daily basis to see if HIV acquisition is reduced.

HIV vaccine – additional data presented from a study stopped in September. The study was the
101 vaccine trial. The product tested didn’t reduce infections and viral load and possible
increased infection for those receiving the vaccine. Analysis of the outcome so far has found
circumcision to be the only significant factor, however, analysis continues.




                                                 8
Study of sero discordant couples – 1 positive and 1 negative
 Positive person didn’t have indications to start therapy: one-half will start therapy and one-
   half will not
 Does therapy lower transmission of HIV to partner

All sessions are available at retroconference.org.

Department of Health – John Peppert
The 2008 legislative session was very quiet for the Office of Infectious Disease and
Reproductive Health.
 HB 3119 related to HIV testing of infants placed in out-of-home care didn’t make it out of
   the House.

The budget will be out later today. A forecast for the Early Intervention Program (EIP) is due to
OFM regarding the $1.5 million surplus. Both House and Senate budgets show a reduction for
EIP.

Most programs in IDRH are still awaiting their grant award information for 2008. Twenty-five
percent of the expected award has been received but a small reduction overall is expected.

The GACHA website has been updated and GACHA now has an email address. It is
GACHA@doh.wa.gov.

Never in Care Project - Jeff Schouten and Bob Wood
There are two Never in Care Projects: one is a CDC sponsored research project in King County
and the other if sponsored with Ryan White funding. A couple of people in the research project
were contacted which caused them concern. They felt the contact was initiated through the
research project which wasn’t the case. Letters were sent explaining the projects and the reasons
why an individual would be contacted.

Region 3 Transition: Open Comments
Two individuals attended and voiced concerns about the transition from Snohomish County to
LifeLong AIDS Alliance of case management and the problems they’ve experienced regarding
continuation benefits.
 LLAA seems unable to communicate directly with the University of Washington (UofW),
    EIP, Medicaid regarding needed dental work.
 They are not receiving benefits supposed to receive.
 There is a possibility of losing 2007 benefits.
 Four releases, some of them blank, have been signed for LLAA
 Transition has been a catastrophe
 Unclear who pays medical bills
 It was stated that only one letter was received stating service would not be provided any
    longer by Snohomish County.
 There has been no response to emails sent to Gail Howard of LLAA.
 They are not aware that a meeting about transition has been held.




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Snohomish County – Alex Whitehouse
 The contract with LLAA began January 1, 2008 for all medical case management services.
 One part-time case manager was kept during the transition through January at Snohomish
   Health District to manage access to care services. All claims were processed through
   January 31.
 LLAA has now assumed providing all the Ryan White care services.
 Whitehouse stated he received no comments with concerns about or any problems with the
   transition.
 Dr. Goldbaum first spoke to a large group of community members and service providers
   about the likelihood of the transition at a Snohomish consortium meeting in October.
   Snohomish Health District case manage staff subsequently conveyed the same information in
   individuals face-to-face meetings with consumers.
 When the transition was approved in early November, letters were sent to a mailing list of
   over 250 clients. Some letters were returned as undeliverable and a few clients have asked
   that mailings not be sent to them. Contact with these individuals was tried by telephone or
   in-person.
 All records were transferred to a medical records specialist at Snohomish Health District on
   January 31, 2008 for those that had not come in to sign paperwork
 February was the first month LLAA is fully funded with Ryan White Part A & B grants.

LLAA
The following responses were made regarding the clients statements.
 Howard indicated the type of work the client needs isn’t covered
 Records indicate the client attended a nutrition meeting at LLAA in Seattle on January 30.
 The client did receive medications in January and February.

Additional information provided about the transition.
 1 case manager plus Howard – 80 to 100 clients seen in last month
 Goal is to be fully staffed (3) by mid-April
 100-125 charts were released to LLAA
 A LLAA ROI needs to be signed by clients.
 LLAA has a letter written and ready to be mailed to those clients that have not come in for
   case management yet.

The following recommendations were made to the clients.
 Review the LLAA grievance process.
 Review the Snohomish County grievance process.
 Send all documentation regarding the issues to John Peppert.

May Meeting
o HIV for foster care
o Inmate panel
o AIDSNET position papers
o LLAA Nutrition Program

The meeting was adjourned at 2:56 p.m.


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