HIV Care in the Washington metropolitan area: A mosaic of

clinical care models

David Wheeler, MDMedical Director,

Inova Juniper ProgramSpringfield, VA

HIV Care in many high-prevalence cities worldwide is provided by one

or two centrally coordinated entities

Ministry of Health and/orGovernment-sponsored health insurance

(Social Security)

Centrally-funded, dedicated HIV services make up only a fraction of the

HIV care available in most American cities

The result is a “mosaic” of concurrently administered and occasionally coordinated

systems of care

I offer the Washington, DC metropolitan area as an example

Sources of data for this presentation

• Washington DC EMA 2012-2014 Comprehensive HIV Care Plan

• Washington DC Health Department (HAHSTA)• Virginia State Health Department

– Northern Virginia Regional Commission• Maryland State Health Department

– Montgomery County Health Department– Prince Georges County Health Department

• Direct queries to non-federally funded clinicians– Self reports of patient volume, based on data bases or best

estimates

Geographic Makeup of Washington, D.C. EMA

The Washington, D.C. EMA consists of: The District of

Columbia Northern and

Northwestern Virginia (17 counties/areas)

Suburban Maryland (five counties)

West Virginia (two counties)

• Overall prevalence: 0.6%

6

Scale of the HIV epidemic

• 34,000 reported to be infected with HIV in the expanded metropolitan area– 17,200 in Washington DC– 9,200 in suburban Maryland– 7,200 in suburban Virginia– 330 in corresponding West Virginia

05/2010 Data as of Dec 2008 7

Maryland Infectious Disease and Environmental Health Administration

June 11, 20128

HIV StatisticsAdult/Adolescent Cases

Washington MSA (Maryland)Reported HIV

Diagnoses during 2010

Living HIV Cases on

12/31/2010

Washington MSA (MD) 511 9,257

Calvert 5 99

Charles 21 298

Frederick 17 275

Montgomery 144 3,051

Prince George’s 324 5,534

Using data as reported through 12/31/2011

Warren

LoudounClarke

Fauquier

Culpeper

SpotsylvaniaKing George

Stafford

Prince William

Fairfax Alexandria

Fairfax City

Arlington

Falls Church

Manassas

Manassas Park City

Fredericksburg

10

Prevalence of HIV in the District of Columbia 2010

0.5%

1.9%

2.7% 2.7%

2.1%

2.6%

3.1%

2.6%

Prevalence

0-1.4%

1.5%-2.4%

2.5%-3.4%

Proportion of persons living with HIV, by Ward, 2010 For 6.3% of cases, ward information was not available

Washington, DC and the inner suburbs# of individuals living with HIV

Sources of funding of HIV care

• Private insurance• Medicaid (medical care for poor people)• Medicare (medical care for elderly and disabled)• Ryan White Care Act (emergency funding for

those without coverage)– Part A, B, C, D, Minority AIDS Initiative

• Other sources (military, veterans, clinical trials)

05/2010 Data as of Dec 2008 12

Standards of HIV Care

• National HIV/AIDS Strategy for the United States (July 2010)

• Department of Health and Human Services HIV Treatment Guidelines Committees

• Specialty Society Guidelines (HIVMA, AAHIVM)• Ryan White Standards of Care

– Monitoring of RW funded sites

05/2010 Data as of Dec 2008 13

Ryan White funded sites in DC and numbers of patients served (2011)

Clincal facility providing primary HIV medical care # of patientsAIDS Healthcare Foundation 31Andromeda Transcultural Center 112Carl Vogel Center 182Children’s National Medical Center 367Christ House 28Family and Medical Counseling 818Howard University Medical Center 430La Clinica del Pueblo 201Regional Addiction Prevention 109Unity Health Care 1735

Whitman Walker Clinic 2449

Washington Hospital Center 580

DC Health Department, 2011 (RW Part C)

Ryan White funded sites in inner suburbs and numbers of patients served (2011)

Clinical facility providing primary HIV medical care # of patients

Greater Baden Medical Services (MD) 312

Montgomery County Health Department (MD) 265

Prince Georges County Health Department (MD) 723

Alexandria City Health Department (VA) 188

Inova Juniper Program (VA) 1024

Loudon County Health Department (VA) 47

Total individuals in HIV Care in 2011 with Ryan White funding 9,601

DC Health Department

How is this care delivered?

What is the typical model of delivering HIV care in the

Washington DC area?

05/2010 Data as of Dec 2008 16

Children’s National Medical Center(365 in RW funded care)

05/2010 Data as of Dec 2008 17

Whitman Walker Clinic(2449 in RW funded care)

• Originally a gay-lesbian health center

• One of the first organizations to address HIV epidemic in DC

• HIV dedicated clinic for many years– Consistently the largest HIV care

facility

• Now a primary care system, with HIV expertise– All clinicians do HIV care– Second site in high prevalence

neighborhood

05/2010 Data as of Dec 2008 18

Unity Health Care(1735 in RW funded care)

• Multi-site community health care system

• Focus on the poor, the under-insured, and underserved

• HIV specialists who travel between health centers in high prevalence neighborhoods

05/2010 Data as of Dec 2008 19

Family and Medical Counseling(818 in RW funded care)

• Community health center in the highest prevalence DC neighborhood

• Special focus on HIV– Staff physicians with HIV

expertise

05/2010 Data as of Dec 2008 20

Washington Hospital Center(580 in RW funded care)

• Large community hospital

• HIV program directed by Infectious Diseases physicians

05/2010 Data as of Dec 2008 21

Howard University (325)/United Medical Center (121)

• University Medical Center– Infectious Diseases clinic– Early intervention clinic

• Community Hospital– Sub-contract from

Howard– Located in high

prevalence neighborhood

05/2010 Data as of Dec 2008 22

Locations of large DC programs funded by Ryan White

• Whitman Walker Clinic– Elizabeth Taylor Center– Max Robinson Center

• Family and Medical Counseling

• Howard University– United Medical Center

• Washington Hospital Center

05/2010 Data as of Dec 2008 23

Unity Health Centers

• HIV care provided in:– 4 clinics in SE– 5 clinics in NE– 1 clinic in SW– 1 clinic in NW

05/2010 DC Health Department data 24

Prince Georges County: Ryan White funded sites

• PG County Health – 723 patients– 2 sites– Dedicated HIV clinics

• Greater Baden Medical Services– 312 patients– Federally qualified

health center– 3 sites offer HIV care

Montgomery County, Ryan White funded sites

• Montgomery County Health Department– 265 patients– Central HIV dedicated

clinic– Aggressive program to

pay health insurance premiums for poor people with HIV

– These individuals are seen in the private setting

Northern Virginia, Ryan White funded sites

• Inova Juniper Program– 1024 patients– HIV dedicated clinic(s)– Hospital administered– Community located

• Alexandria City Health Department– 188 patients– Clinic co-managed with

community health center

The treatment “gap”

• 32,300 infected in DC and inner counties– 9,600 in Ryan White funded care

• 17,000 living with HIV in DC– 7,000 in Ryan White funded care

• 5,500 with HIV in PG County– 1,030 in RW funded care

• 3,000 with HIV in Montgomery County– 265 in RW funded care

• 6,800 with HIV in inner counties of NoVa– 1,250 in RW funded care

05/2010 Data as of Dec 2008 28

Where do the other patients receive their care?

Or ARE they in care?

05/2010 Data as of Dec 2008 29

Ryan White funded sites also see patients who have another payer source

• Juniper Program (Virginia)– 1300 patients in primary medical HIV care– 1024 funded by Ryan White

• AIDS Healthcare Foundation (DC)– 400 patients in care (report from clinical data

base)– 31 in care through Ryan White

05/2010 Data as of Dec 2008 30

Clinical care systems with regional coverage (and excellent data bases)

• Kaiser*– Virginia (400 patients in

care)– Maryland/DC (1500

patients in care)

• Veterans Administration Medical Center*– 1,000 patients in care

• Military Medical Center– Numbers unavailable

05/2010*Based on verbal report of

clinical data bases31

University Medical Centers

• Georgetown University Medical Center

• George Washington University Medical Center– Dedicated HIV clinics run

by Infectious Diseases divisions

– About 1800 total patients in care, based on best estimates

05/2010 Data as of Dec 2008 32

Private practices

• Five large private practices in inner Northwest DC– Infectious Diseases– Internal Medicine– Many focus on gay men’s

health– About 2500 patients in care

• Two ID practices in NE– One private practice– One hospital based– About 600 patients in care

05/2010 Self reported estimates 33

Prince Georges County

• Private practices– 3 solo private

practitioners– Approximately 700

patients in care

• Dimensions Health Care– Hospital affiliated,

HIV/ID clinic– Previously RW funded– About 100 patients in

care

05/2010 Data as of Dec 2008 34

Montgomery County

• Four group ID practices– Several specifically

partner with health department to receive patient with newly obtained health care coverage

– About 1500 patients in care

05/2010 Data as of Dec 2008 35

Northern Virginia

• Four group ID practices– About 1450 patients in

care

• Six solo ID practices– About 600 patients in

care

05/2010 Data as of Dec 2008 36

Re-assessment of treatment gap in DC and inner suburbs

• Estimated number living with HIV

• Reported number in Ryan White funded care

• Estimated number receiving care outside of the Ryan White system

• 32,300

• 9,600

• 12,500– Kaiser, VA: 2,900– DC: 4,900*– PG, Montgomery:

2,300*– Northern Va: 2,400*

05/2010 *Includes self-reported estimates 37

Tracking and monitoring HIV care in the Washington, DC area

• Ryan White cross-part collaborative– Data base integration– Quality assurance indicators and activities– Only involves Ryan White funded sites

• DC cohort– Prospective observational cohort of DC-based clinics and

academic centers (RW and non-RW)– NIH funded

• AIDS Education and Training (AETC) funding– Roundtable meetings– Encourage collaboration among HIV treating clinicians

05/2010 Data as of Dec 2008 38

Summary

• A wide range of care systems are involved in HIV care in the Washington, DC area

• Those that are funded by the Ryan White Care Act are closely tracked, monitored and evaluated

• At least as many HIV infected individuals are receiving their care outside of the Ryan White funded network

05/2010 Data as of Dec 2008 39

Current models of HIV care include:

• Dedicated, University based HIV clinics– Georgetown, GW, Howard

• Community hospital based HIV clinics– Washington Hospital Center, Providence, United

Medical Center• Community hospital administered but

community located, HIV dedicated clinics– Inova Juniper Program

05/2010 Data as of Dec 2008 40

Current models of HIV care include:

• Traditional HIV-dedicated clinic, moving into primary care– Whitman Walker clinic

• Traditional community heath center, with a specific emphasis on HIV care– Family and Medical Counseling

• Clinics that target specific populations– La Clinica del Pueblo (Latin community)– Regional Addiction Prevention (IDU)

05/2010 Data as of Dec 2008 41

Current models of HIV care include:

• Multi-site community health centers (which provide all primary care services), in which HIV specialists travel to the patient– Unity, Greater Baden Medical Services

• Multi-site, integrated health systems, (which provide all primary care services) in which the patient travels to the HIV specialist– Kaiser, VA, military

05/2010 Data as of Dec 2008 42

Current models of HIV care include:

• County health departments with centralized, HIV-dedicated clinics– Prince Georges County

• County health departments with an aggressive program of purchasing access to health insurance for clients(and referring to the private setting)– Montgomery County

05/2010 Data as of Dec 2008 43

Current models of HIV care include:

• Private practitioners– Serving insured, gay men in NW DC– Serving insured patients in high prevalence, low

income neighborhoods• NE DC, Prince Georges County

– Suburban group and solo ID practices• Montgomery, Prince Georges, Northern Virginia

05/2010 Data as of Dec 2008 44

Mosaic of care models

• Working in parallel• Address needs of

various communities• Only a fraction is

centrally monitored• There may be a

duplication of effort• Difficult to respond as a

metropolitan area

05/2010 Data as of Dec 2008 45

Future directions

• Health care reform in the United States may contribute to a change in the way HIV care is funded in the DC area

• This may change the way in which HIV care is delivered

• Some of the models of care in the DC metro area may be more successful in providing high quality HIV and related primary care than others

05/2010 Data as of Dec 2008 46

Tracking and monitoring

• A more comprehensive system of tracking and monitoring of HIV care across the metropolitan area may help to address:– Availability of HIV care within neighborhoods in

the metro area– Quality of care delivered in various settings– Capacity building and mentoring between

experienced and novice HIV clinicians– Assessing the best HIV care models for the future

05/2010 Data as of Dec 2008 47

Thank you.

05/2010 Data as of Dec 2008 48