Opinion: 3 steps health plans can take to end the HIV epidemic

We have a path to ending the HIV epidemic in the United States, but it requires health plans and healthcare purchasers to take a more active role in getting us there. 

People with HIV who are on antiretroviral therapy are highly unlikely to transmit infection.  Yet, roughly seven in 10 new infections arise from the half of all people living with HIV who have been diagnosed, but are not receiving regular HIV care.

If we can get all of these persons into care and on treatment, we can stop transmission.

Many are insured, but not receiving specialized HIV care or have stopped antiretroviral treatment.  The health system needs to build the capacity to routinely monitor all people diagnosed with HIV and support them to engage in care and take active steps to reengage them if they have interruptions in care.

HIV is rarely a frontpage headline these days, yet it still is a major public health threat in the United States with more than 1.2 million people living with HIV and roughly 44,000 new infections each year.

Recently, significant scientific progress has emerged just as renewed steps are being taken to re-energize the response to HIV, including the development of our country’s first comprehensive National HIV/AIDS Strategy released by President Obama in 2010 and updated in 2015.

Randomized trials have proven the effectiveness of sustained HIV viral suppression at improving HIV outcomes and reducing transmission, bolstering the case for access to stable, comprehensive insurance coverage.

Fortunately, there are a small number of practical steps that will both improve individual patient outcomes and curb the epidemic. I recently coauthored a report for amfAR, the Foundation for AIDS Research, “Curbing the HIV Epidemic by Supporting Effective Engagement in HIV Care: Recommendations for Health Plans and Health Care Purchasers.”

According to the report, efforts should concentrate in three areas:

1. Monitoring

To improve outcomes and reduce costly medical interventions, it is necessary to strengthen the systematic monitoring of engagement in care and viral suppression. Health plans and purchasers should actively monitor national HIV quality metrics, adopt new metrics to identify and intervene with patients disengaging from care (such as by tracking missed clinic visits) and build quality improvement systems that include persons “not in care.”

2. Intervening

Living with HIV, accessing care in a complex healthcare system, and adhering to antiretroviral therapy over one’s life is challenging even for the most motivated individuals. Major life challenges, transitions, and stressors such as unemployment, relationship distress, family responsibilities, and financial distress create immediate, high-priority needs that can compete with engaging in HIV care.

Some estimates suggest that about 25% of patients churn in 12-month cycles.

The steps that health plans and purchasers should take to address these issues include:

• Maximizing the capacity of electronic health records to streamline and routinize HIV screening in accordance with CDC recommendations;

• Screen for cases of acute infection and intervene promptly with health departments or community partners to interrupt transmission;

• Expand low-cost evidence-informed approaches to promote retention in care; and

• Actively work to reengage people in care who have experienced treatment interruptions (including tracking down people who stop coming to the clinic and addressing treatment barriers).

Next: Working for policy change

3. Working for policy change

Health plans also should seek opportunities to engage with health departments, purchasers, and providers to enact policies that facilitate the delivery of high quality care, while also reducing costs. For example, they should work to establish “Data to Care” programs in all state health departments that use HIV surveillance data. This can help health plans target efforts to enrollees with HIV who have stopped engaging in care; establish standards for Medicare, Medicaid, and marketplaces to monitor core HIV indicators; and create a level playing field for health plans by requiring fidelity to HHS antiretroviral therapy guidelines.

HIV is not an intractable problem.  Health plans and purchasers can achieve better patient outcomes that also will move us closer to ending HIV as a public health threat in the United States.

Jeffrey S. Crowley is a distinguished scholar at the O’Neill Institute for National and Global Health Law at Georgetown Law. Crowley served as the Director of the White House Office of National AIDS Policy and Senior Advisor on Disability Policy from 2009-2011.  In this role, he led the development of the National HIV/AIDS Strategy for the United States.