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					           Outreach: The Challenges
             From Case Finding to
     the Provision of Comprehensive Care
                            8th Annual Clinical Conference
                       for the Ryan White CARE Act Grantees
                                    June 16, 2005

                          Laura W. Cheever, MD, ScM
                 US Department of Health and Human Services
                 Health Resources and Services Administration
                               HIV/AIDS Bureau


LW Cheever, MD.
Presented at IAS–USA/RWCA Clinical Conference, June 2005.
                                                                              Slide #2


     RWCA Spending on Outreach
         Title               Amount                   Percent of Total
                                                   Mean Median Range
     Title I*           $17,311,596                 2.2     2.8    0-25.1
     Title II*          $4,465,226                    1.2            0.7    0-10.8
     Title III**        $5,306,087                    3.0            1.6    0-21.2
     Title IV**         $5,763,803                    5.2            6.4    0-10.6
     TA                 $2,600,000                  22.0
     * Based on 2003 Allocations Data EIS + Outreach Services
     ** Based on estimates from random selection of 2004 grants


LW Cheever, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
                                                                                 Slide #3

                                     Continuum
                                  Engagement in Care
       Not in                                                                 Fully
       Care                                                                   Engaged

     Unaware of       Know         May Be          Entered         In and     Fully
     HIV Status       HIV          Receiving       HIV             Out of     Engaged
     (not tested      Status       Other           Primary         HIV Care   in HIV
     or never         (not         Medical         Medical         or         Primary
     received         referred     Care But        Care But        Infreque   Medical
     results)         to care;     Not HIV         Dropped         nt User    Care
                      didn’t       Care            Out
                      keep                         (lost to
                      referral)                    follow-up)




LW Cheever, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
                                                                              Slide #4

              Persons Living with HIV or AIDS by
               Diagnostic Category, U.S., 2000*
               1,000,000

                900,000

                800,000                           230,000                   HIV Undx‟d
                700,000
                                                (180-280K)
                                                                            HIV Est.
                600,000
                                                 200,000                    HIV Dx‟d
                500,000
                                                                            AIDS
                400,000                          130,000
                300,000

                200,000                          340,000
                100,000

                      0
                                            All Living HIV
         *AIDS from all states; HIV from 25 HIV reporting states;
         estimated HIV from model for remaining states; undiagnosed
                                                     Souce: Slide from Glynn, CDC
LW Cheever, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
                                                                                 Slide #5

         Proportion of HIV and AIDS cases*
         diagnosed during 1999 who had >1
          CD4 count reported by June 2001

                                        HIV                   AIDS
                                     (N = 4556)            (N = 3597)
                                         %                     %
                  CD4                    39                    93
                 No CD4                  61                     7

       *AR, CO, ID, LA, MO, MS, NJ, OK, SC, TN, WV, WY
                                                             Souce: Slide from Glynn, CDC
LW Cheever, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
                                                                                 Slide #6
           Persons Living with HIV or AIDS by
          diagnostic category, U.S., 2000* and
         1,000,000
                   number with no CD4 count
           900,000
           800,000
                                230,000                                          230,000
           700,000
           600,000
                                                                                 122,000
           500,000              200,000
           400,000              130,000                                            79,300
           300,000
           200,000                                                                 23,800
           100,000              340,000
                 0
                                  All HIV                         CD4 count
            *AIDS from all states; HIV from 25 HIV reporting states;
            estimated HIV from model for remaining states; undiagnosed
                                                            Souce: Slide from Glynn, CDC
LW Cheever, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
                                                                                     Slide #7
               Main Reason for HIV Test*, by Gender,
          June 1997 - December 2000 (Supplement to HIV and
                                AIDS Surveillance Project)




   Male                                                                               Female
 (n=5,282)                                                                           (n=1,954)




                      Illness                  Recommended by health care provider
                      In at-risk group         Jail Screening
                      Sex partner at-risk      Other
                      Test offered by clinic

                                                 Souce: Slide from R. Romaguera, CDC
                * At first (+) HIV test
LW Cheever, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
                                                                            Slide #8

         First CD-4 Count after Testing
       From ~5000 Interviews conducted May 2000- Dec 2002




                                    31.53%
                                                    40.30%
                                   (>=500)
                                                    (< 200)



                                        27.00%
                                       (200-499)




                                              Souce: Slide from R. Romaguera, CDC
                                 Unpublished SHAS Data
LW Cheever, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
                                                                                   Slide #9

                 Delays in Seeking Care
       189 HIV infected patients seeking primary
         care: First HIV test
            >1 year ago         39%
            >2 yrs ago          32%
            >5 yrs ago          18%
                                               Samet, Arch Intern Med 1998

       Those delaying care more likely to be
        marginalized- poverty, addiction, lack of
        insurance
                                     Source: Samet, AIDS; Raveis, AIDS Care 1998
LW Cheever, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
                                                                                    Slide #10

        894,000                Estimates of ART Use:
                                     US 2003
                                 519,000
        746,000
                                                           360,000
        820,000
                                 441,000                                        283,000

                                 480,000                   320,000
                                                                                253,000
                                                           340,000
                                                                                268,000


           Total                 PLWHA                    PLWHA             PLWHA eligible
          number                eligible for             eligible for       for ART, in care,
          PLWHA                 ART (CD4                   ART in           receiving ART
                                   <350)                     care
                                                 Souce: Teshale, Abs 167, CROI 2005
LW Cheever, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
                                                                                Slide #11



                   Access to HAART 2001
                      On HAART 84%
                                                          AOR HAART
                Factor                                    Use
     African American                                     0.84
     IDU as Risk Factor                                   0.86
     Female                                               0.81
     <4 Outpatient visits/yr                              0.75
     CD4 > 350 cells/ml3                                  0.75

                                                            Source: Gebo, JAIDS, 2005
LW Cheever, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
                                                                            Slide #12

          Are We Reaching Those Not in
                    Care?

                                                    HIV primary care appt.
             Study                                     within 6 months
     INSPIRE (IDUs)                                                79 %
     INSPIRE Miami Site                                            67 %
     SPNS – Outreach Init.                                         88 %




LW Cheever, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
                                                                                 Slide #13

                                     Continuum
                                  Engagement in Care
       Not in                                                                 Fully
       Care                                                                   Engaged

     Unaware of       Know         May Be          Entered         In and     Fully
     HIV Status       HIV          Receiving       HIV             Out of     Engaged
     (not tested      Status       Other           Primary         HIV Care   in HIV
     or never         (not         Medical         Medical         or         Primary
     received         referred     Care But        Care But        Infreque   Medical
     results)         to care;     Not HIV         Dropped         nt User    Care
                      didn’t       Care            Out
                      keep                         (lost to
                      referral)                    follow-up)




LW Cheever, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
                                                                                                Slide #15

        Outreach Interventions: Case Management
                                       CM vs. SOC stratified by drug use
                            80

                                                                       Non-Drug Users N=202
                            70
                                                                                    OR=2.2
                                                                                    p=0.008
                            60
         % linked to care




                            50
                                 Drug Users N=71
                            40    OR=1.1 p=n.s.

                            30


                            20
                                  CM         SOC                           CM          SOC
                            10


                            0

                                              recent drug-Yes   recent drug-No

                                                                             Souce: Gardner, AIDS, 2005
LW Cheever, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
                                                                                                            Slide #16
                                                       Support Services and
                                                        Retention in Care
     Proportion of patients in year 1



                                        70
                                                                       62         64
                                                             61
                                        60        55
                                        50
                                             38         39        39         39        Without regular
                                        40                                             service
                                        30                                             With support services
                                        20                                             care
                                        10                                             n=2647
                                        0                                              • 20% increase in regular
                                                                                       visits (>2/year) in an urban
                                             Case      Transp.    Mental     Chem      clinic with support services,
                                             mgmt                 health    depend     1997-1998
                                                       Support service

                                                                       Source: Sherer R, et al. AIDS Care, 2002
LW Cheever, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
Medicare Part D and HIV/AIDS:
 What a Clinician May Want
          to Know
            8th Annual Clinical Conference
       for the Ryan White CARE Act Grantees
                    June 16, 2005


             Laura W. Cheever, MD, ScM
    US Department of Health and Human Services
    Health Resources and Services Administration
                  HIV/AIDS Bureau
                                                                            Slide #18

                Medicare and HIV/AIDS
      Approximately   60,000-80,000 Medicare
        beneficiaries with HIV/AIDS
             Qualify primarily through being on Social
              Security Disability Income (SSDI) for 2+ years
             Currently no prescription benefit
      70-85%            also qualify for Medicaid
             „Dually eligible‟ or „dual eligibles‟
             Approximately 50,000-60,000 individuals
             Medicaid currently provides prescription drug
              coverage
LW Cheever, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
                                                                            Slide #19

     Medicare Modernization Act (MMA)
      Adds  a prescription drug benefit to
        Medicare, known as Medicare Part D
             Benefit starts January 1, 2006
             Most Medicare beneficiaries must elect the
              benefit and choose a plan
             Dually eligible beneficiaries will be
              automatically enrolled in Medicare Part D
              because prescription drug coverage will
              switch from Medicaid to Medicare January 1
             Plan formularies must include all
              antiretrovirals
LW Cheever, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
                                                                                            Slide #20


           Basic Plan: Beneficiary Cost
      Monthly   premium (around $37 in 2006)
      $250 deductible
      25% coinsurance from $250 to $2,250*
      100% coinsurance from $2,250 to $5,100
      Catastrophic coverage level: co-pay of 5%
       after total drug costs reach $5,100 and
       beneficiary has paid $3,600 in true out-of-
       pocket costs (TrOOP)
     •Coinsurance is a term used in Medicare Part D that refers to the beneficiary’s contribution toward
      prescription drug costs until the catastrophic coverage level has been reached
LW Cheever, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
                                                                            Slide #21


                  Low-Income Subsidies
      Most Medicare beneficiaries with HIV/AIDS will
       qualify for some type of low-income subsidy
      Dually eligibles, Medicare beneficiaries on
       Supplemental Security Income (SSI) or in a
       Medicare Savings Program (QMB, SLMB, QI)
       will automatically be eligible
      Beneficiaries who aren‟t included in the group
       above but meet income and asset criteria need
       to apply to Social Security or Medicaid to qualify
       for a subsidy
      Subsidy counts toward out-of-pocket costs and
       reaching catastrophic coverage level
LW Cheever, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
                                                                                                      Slide #22
       Main Benefit and Low-Income Provisions                                      Plan Pays
       All numbers are for 2006                                                    Beneficiary Pays


       Main Drug Benefit for Beneficiaries >150% FPL
       or less than 150% FPL but more than the asset limit
       $35 / month estimated premium
      $250                   $2250                $5100                                     $+

                   75 %                                                   About 95%


       Beneficiaries <150% FPL who also meet the asset test
       ($10k individual / $20k couple)*
       Sliding scale premium from $0 to the estimated $35 / month $5100                     $+
      $50
                                                                               $2 - $5
                                    85 %                                    co-pays apply

       Beneficiaries <135% FPL who also meet the asset test*
       (3X SSI limits, $6k individual / $9k couple) and
       Full benefit dual eligibles who are beneficiaries >100% FPL
       $0 premium                                       $5100                               $+
                                   $2 - $5
                                co-pays apply                              100 %


       Full Dual Eligibles who are beneficiaries 100% FPL*
       $0 premium                                   $5100                                   $+
                                   $1 - $3
                                co-pays apply                              100 %

LW Cheever, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.                   Slide from CMS, DHHS
       * Cost sharing is $0 if the beneficiary is on Medicaid and institutionalized.
                                                                            Slide #23


          Case Study: Jane Matthews
        On SSDI, Medicare and Medicaid (dual eligible)
        SSDI benefit $780/month (less than 100% FPL)
        Antiretroviral regimen is efavirenz and FTC/TDF
        Drugs cost $1,300 per month
        Jane pays $6 in co-pays per month for two
         scripts (income < 100% FPL so $3 brand name
         co-pay applies) for three months
        By 4th month, total drug cost of $5,200 exceed
         $5,100 catastrophic coverage level ($1,300 x 4)
        No cost to Jane after that
        Jane pays $18 for the year [3 months of $6 co-
         pay]
LW Cheever, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
                                                                            Slide #24

              Case Study: Jason Smith
      On  SSDI, Medicare and small private
       disability insurance benefit
      Income $1,100 per month (138% FPL)
      Same drug regimen and costs




LW Cheever, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
                                                                            Slide #25


              Case Study: Jason Smith
        Jason pays:
           $9.25 per month premiums (75% subsidy of $37)
           Month 1: $50 deductible plus $187.50 (15% co-

            insurance of $1,250 balance)
           Month 2: $195 coinsurance (15% coinsurance of

            $1,300)
           Month 3: $195 coinsurance (total drug costs $3,900)

           Month 4: $180 coinsurance (on $1200 balance of

            $5100 total drug cost limit for catastrophic coverage
            level)
           Months 5-12: $10 per month ($5 brand name co-pay on

            two scripts)
        Jason pays $998.50 for the year [$111 in premiums,
         $807.50 in deductible and coinsurance, $80 in co-pays]
LW Cheever, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
                                                                            Slide #26

            Case Study: Charlie Jones

     65 years old, HIV positive, aged into
      Medicare
     Income $1,600 per month (200% FPL)
     Same drug regimen and costs




LW Cheever, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
                                                                            Slide #27


            Case Study: Charlie Jones
        Charlie pays:
           $37 per month premiums

           Month 1: $250 deductible plus $262 (25% co-
            insurance) towards $1050 balance
           Month 2: $237 coinsurance (25% of $950 balance to
            reach $2250 co-insurance limit) plus $350 (100%
            coinsurance for balance of $1300 pharmacy cost)
           Month 3: $1,300 prescription cost (100%) [Charlie has
            now paid $2,399 out-of-pocket towards his drugs]
           Month 4: $1,201 prescription cost (100% coinsurance
            for a total of $3,600 in out-of-pocket costs). Total drug
            costs are also above the $5,100 limit so the
            catastrophic coverage level has been reached.
           Months 5-12: $65 per month (5% co-pay)

        Charlie pays $4,564 for the year [$444 in premiums,
         $3600 out-of-pocket and $520 in co-pays]
LW Cheever, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
                                                                            Slide #28

                Further Help With Costs
      AIDS   Drug Assistance Programs (ADAP),
        in accordance with State program policy,
        can pay:
             Premiums
             Deductible
             Coinsurance (15%, 25% and 100%)
             Co-pays
      ADAP    contributions do not count toward
        the $3,600 in out-of-pocket costs needed
        to reach the catastrophic coverage level
LW Cheever, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
                                                                     Slide #29

                        Provider Role
     June,     2005
           Dual eligibles will get letters from Medicare
            telling them they will be auto-enrolled in
            Medicare Part D
           Beneficiaries with low incomes may get letters
            from Social Security about applying for low
            income subsidies
     You     can:
            Encourage Medicare patients to apply for
             subsidies
          Tell dual eligibles to hold onto letters for their

             records
LW Cheever, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
                                                                            Slide #30

                              Provider Role
      October,            2005
             “Medicare and You” sent to all beneficiaries
              with plan information
             Dual eligibles will get letters notifying them of
              the plan into which they are automatically
              enrolled
      You       can:
             Encourage Medicare beneficiaries to enroll
             Tell dual eligibles that they can choose a
              different plan
             Refer patients to www.Medicare.gov or 1-800-
              Medicare
LW Cheever, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
                                                                            Slide #31


                              Provider Role
      January           1, 2006
             Dual eligible beneficiaries will receive drugs
              through Medicare plan
      You       can:
             Prescribe extra antiretroviral medication to
              “bridge” transition period so that treatment
              regimen is uninterrupted
             Ask about access to medication


LW Cheever, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
                                                                            Slide #32




    Laura W. Cheever, MD, ScM
        5600 Fishers Lane
       Rockville, MD 20874

       Telephone: 301-443-1993
      Email: LCheever@hrsa.gov

LW Cheever, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.