Promising Practices from Enhanced Planning and Initial Implementation

Decision Making

Between October 2010 and March 2011, ECHPP communities engaged in rapid assessment (i.e., less than 6 months) and strategic review of existing local HIV prevention programming. Gathering relevant current local information on the status of prevention programs and service gaps that needed to be addressed often proved difficult and time-consuming, but was vital to the process. Deciding how to reallocate resources required consideration of factors and information from a variety of data sources, including local epidemiologic data, cost-effectiveness data, evidence of local partners’ capacity and engagement in service delivery, etc. Below are examples of approaches that ECHPP grantees used to navigate challenges related to data collection, synthesis and use for reallocating resources to increase the effect of their HIV prevention portfolios.

• Updating local inventories of HIV prevention services and information sources
• Using multiple data sources in planning (including efficacy, cost and local epidemiologic data)
• Mathematical modeling

Updating Local Inventories of HIV Prevention Services and Information Sources

Conducting a thorough and broad review of local HIV prevention service resources helped health departments identify important gaps in prevention and opportunities for strengthening and improving coordination of services. Although many health departments have a needs assessment on file, conducting the situational analysis for ECHPP highlighted new or emerging prevention program or data needs and service gaps.

• To develop the ECHPP plan for Miami, Florida State Department of Health (FLDOH) partnered with Miami-Dade County Health Department and the Health Council of South Florida (a non-profit organization that conducts regional planning activities) to implement a process that directly engaged multiple HIV service providers, consumers of these services, and other stakeholders in the Miami area. FLDOH has long maintained a standing partnership network of diverse local stakeholders, involved with and affected by HIV prevention and care. This network included medical and non-medical HIV service providers within and outside of government, as well as local community residents representing populations affected by HIV. Using this network, FLDOH implemented various methods to gather input for planning, including key informant interviews, focus groups, community listening sessions, and stakeholder meetings. By leveraging and expanding upon its existing relationships with a variety of partners, FLDOH was able to identify key coverage and gaps in service provision in the area, and thus created an action plan that was well-tailored to community needs and priorities. For example, this process showed that five neighborhoods in the Miami-Dade County region had some of the highest needs for improved HIV prevention and treatment services. This finding subsequently was used to focus implementation of many ECHPP interventions in those five areas.
• To facilitate better communication between public and private HIV prevention and treatment providers, the Puerto Rico ECHPP team compiled a new, 156-page HIV service directory. In addition to providing an overview of the HIV epidemiologic situation on the island, the directory lists the contact information for and describes the types of services offered by numerous community- based organizations, local municipal programs, offices within the Department of Health, and a variety of other resources and organizations in specific locales on the U.S. mainland which benefits persons who frequently travel between the island and these locales. The new directory facilitates collaboration and referral of HIV clients by making health care providers aware of local services. It also helps to strengthen service referrals, communication, collaboration, and coordination between organizations involved with HIV prevention and treatment. The Puerto Rico ECHPP team plans to distribute copies of the directory to all the organizations and offices serving local communities affected by HIV, as well as make it available to the general public via the Department of Health’s Internet site.

Using Multiple Data Sources in Planning (including efficacy, cost and local epidemiologic data)

In order to conduct planning in support of HIP, it was necessary to draw on a wide variety of relevant data sources. Considering programmatic and resource allocation decisions within the context of local epidemiology was essential, but not sufficient. It was also important to consider current effectiveness data about intervention strategies, information about local capacity to scale up specific interventions, and cost data. Indeed, applying return on investment or cost-effectiveness analytic tools or frameworks to the assembled data was particularly helpful to decision makers, many of whom continue to grapple with reductions in the resources available to support HIV prevention.

• During the ECHPP planning process, the District of Columbia’s HIV/AIDS, Hepatitis, STD, and TB Administration (HAHSTA) used police data on locations of prostitution and drug arrests to identify neighborhoods where condom distribution, HIV testing, and syringe exchange efforts were more likely to reach high-risk individuals. HAHSTA also obtained maps of liquor stores, check cashing locations, barbershops, hair salons, and laundromats from the Licensing Board of DC’s Office of Planning. By geocoding these locations, HASTA was able to identify potential new partners and venues for prevention activities in priority neighborhoods.
• Many jurisdictions applied locational mapping techniques to local epidemiologic and Geographic Information System (GIS) data in order to better align available HIV prevention services with the needs of local populations. For example, the Los Angeles County Department of Public Health Division of HIV and STD Programs used geospatial analysis to implement a syndemics planning model and target local services to areas where multiple disease epidemics interacted and challenged the population.

Mathematical Modeling

Mathematical modeling can aid planning efforts by synthesizing program cost, efficacy and other data to identify the most cost-effective approaches to HIV prevention, clarify priorities, and guide resource allocation decisions. However, mathematical models cannot incorporate all aspects of decision making and rarely provide the final word on the best use of resources. Modeling results should not, therefore, be viewed as formulas for prevention; rather, they provide additional sources of input for planners charged with making critical program decisions.

Several jurisdictions collaborated with academic and private partners to develop and apply mathematical models that could help health departments decide how to allocate their available HIV prevention resources. Each jurisdiction used a slightly different approach, but in every case, the options and additional information the models produced were considered when making final decisions about aligning resources. The Maryland Department of Health and Mental Hygiene, for example, utilized mathematical modeling to analyze the cost effectiveness of various HIV testing approaches, develop a resource optimization model to inform the allocation of current resources, and quantify the additional resources that would be needed to reach the prevention goals of the NHAS. The New York City Department of Health and Mental Hygiene used a mathematical model to examine optimal combinations of HIV prevention strategies that could maximize the number of new infections averted given current and expected future funding constraints. The Los Angeles County Department of Public Health Division of HIV and STD Programs utilized a Robust Decision Making modeling approach to examine options for distributing existing resources to have the greatest effect in HIV prevention as well as to quantify the risks and benefits of outcomes associated with each option.

Partnerships

Strong and productive partnerships are critical to the successful implementation of jurisdictional HIV prevention plans. ECHPP has both strengthened existing relationships between health departments and community partners and provided a focal point for new partnerships that support a more coordinated response to local HIV epidemics.

• Engaging community, stakeholder, and prevention partners
• Creating new and sustainable partnerships
• Key partnerships in local government

Engaging Community, Stakeholder, and Prevention Partners

The local communities most affected by HIV are essential allies and partners in prevention. Engaging these communities’ support for and input into the bold shifts needed to increase the effect of HIV prevention efforts is critical to reaching the goals of the NHAS.

Engaging community, stakeholder, and prevention partners The local communities most affected by HIV are essential allies and partners in prevention. Engaging these communities’ support for and input into the bold shifts needed to increase the effect of HIV prevention efforts is critical to reaching the goals of the NHAS.

• To engage the local community and communicate the urgency associated with its planning activity, Houston Department of Health (HDOH) described its effort as an ’emergency response to the National HIV/AIDS Strategy’. HDOH invoked the NHAS as a focal point in discussions to communicate that the context for HIV prevention is shifting and that jurisdictions must be prepared to adapt quickly. It also allowed the HDOH to communicate with urgency that HIV prevention remains a priority. A key activity promoted using this frame was the targeted public health and community mobilization effort called the SAFER Initiative (Strategic AIDS/HIV Focused Emergency Response Initiative: A Local Response to the National HIV/AIDS Strategy). The SAFER Initiative aimed to increase social awareness throughout five targeted communities. HIV prevention activities were put into the context of other prominent issues of concern within each of the five communities.
• Florida used several methods to engage community members, prevention partners and other stakeholders in its situational analysis. Prior to ECHPP, state and local officials in Florida had long-standing stakeholder committees and informal mechanisms to solicit input and support for public health efforts in Miami-Dade County. After ECHPP began, members of the health department were able to build on and further strengthen these existing relationships at frequent intervals. During the early ECHPP planning phase, the state and local DOH, together with the Health Council, presented progress updates and solicited detailed input from the stakeholders. Many of the stakeholder recommendations were incorporated into the Miami-Dade County ECHPP goals and objectives. After implementation began in April 2011, the Florida ECHPP staff continued to seek stakeholder feedback through additional periodic meetings. Stakeholder feedback currently is being used to improve on-going ECHPP implementation activities. Florida’s stakeholder engagement process continues to provide opportunities for ongoing meaningful input and involvement. This process promotes a sense of community ownership of the local ECHPP plan, and supports optimal tailoring of the implementation activities in order to address local HIV prevention and treatment needs in the Miami-Dade County region.
• Chicago Department of Public Health conducted a series of focus groups to get structured input from several key groups in the local community, including the Chicago Gay Black Men’s Caucus, substance users, service providers and HIV planning leadership in Chicago. This direct engagement provided important input during ECHPP planning and also informed, and therefore strengthened, the City of Chicago’s development of a strategic and coordinated response to HIV.
• Recently, San Francisco Department of Public Health’s HIV Prevention (SFDPH) Section (HPS) incorporated community engagement into its organizational mission. Two HPS units have staff dedicated to ensuring community voices are incorporated into SFDPH planning and policy efforts. The Community Engagement and Policy Unit focuses on incorporating voices from San Francisco communities affected by HIV, whereas the Community-Based Prevention Unit focuses more narrowly on engaging clients of HIV prevention services. In addition, the HIV Prevention Planning Council conducts at least two community forums each year. These efforts support San Francisco’s general strategy for implementing ECHPP project goals.
• The Dallas ECHPP plan emphasized expanding HIV prevention efforts for black gay men by enhancing the capacity and leadership of communities and organizations to provide effective, comprehensive HIV prevention programming. Such leadership development supports a much needed comprehensive and coordinated HIV prevention process among African American MSM in Dallas. The Dallas Health Department is supporting this type of capacity building to increase the number of stable community-based prevention organizations throughout Dallas in order to increase capacity to achieve local HIV prevention goals.

Creating New and Sustainable Partnerships

Many ECHPP plans included activities that increased collaboration internally within the health department as well as externally among HIV service organizations. Making major shifts in HIV prevention included creating new and strengthening existing partnerships with a variety of important stakeholders. Partnered organizations must function in a more coordinated fashion to successfully implement these combinations of public health strategies. Broadening partnerships with providers and other entities has also been an important aspect of the ECHPP plans. ECHPP grantees have been able to build on existing partnerships and create new ones to improve coordination and expand reach of programmatic activities.

Internally, collaborations among HIV prevention, care and treatment units within the health department have been and continue to be important for jurisdictions developing a comprehensive HIV prevention plan. Various structural factors (e.g., separate funding streams and planning efforts) have created and sustained long-standing HIV prevention and care silos within many ECHPP-funded health departments. By successfully bridging these silos, ECHPP grantees have better positioned themselves to execute the ambitious shifts in comprehensive HIV prevention planning required for ECHPP and for implementing the NHAS. Growing and sustaining these collaborations will also help to support long-term improvements in community and public health operations.

• In order to scale up condom distribution for general public and at-risk heterosexuals, the District of Colubmia HIV/AIDS, Hepatitis, STD, and TB Administration (HAHSTA) obtained police data on locations of prostitution to identify priority neighborhoods. HASTA also obtained a map of local businesses from the Licensing Board of DC’s Office of Planning. Geocoding of the locations enabled identification of potential new partners and venues for condom distribution in these neighborhoods. Business owners were then recruited to distribute unlimited free condoms, These new partners included bars, hotels, liquor stores, restaurants, laundromats, barber shops, and other businesses, half-way houses and prison reentry programs, non-public health locations, social networks of HIV-positive heterosexuals and IDUs, faith-based communities. HAHSTA also identified partners to initiate new distribution activities for the District of Columbia (e.g., fraternity/sorority organizations, online entities). HAHSTA posted location information for partners distributing free condoms on its website and introduced a text messaging service for consumers to find free condom distribution locations by zip code.
• The San Francisco Department of Public Health’s (SFDPH) HIV Prevention Section (HPS) Community-Based Prevention Unit facilitated the development of service provider networks. These networks are organized with specific missions that support seamless coordination of services. For example, provider networks that focus on testing, Prevention with Positives (PWP), and services for Latinos have been established. These networks meet regularly to share best practices, establish mechanisms for service coordination and client referral, and identify service duplication and gaps.
• Nine ECHPP health departments have benefited from research-program partnerships with the National Institutes of Health Centers for AIDS Research (CFARs). In consultations with participating health departments, these CFARs have conducted small focused research projects to support local implementation strategies. For example, the Emory University CFAR provided training and technical assistance to the Georgia Department of Public Health supporting the implementation of Couples Voluntary Counseling and Testing (CVCT) in four metro-Atlanta area community-based organizations.
• Philadelphia Department of Public Health’s AIDS Activities Coordinating Office (AACO) built upon the integrated administration of HIV care and prevention resources. AACO is the single administrator of 17 HIV funding streams, including local, state, Ryan White Parts A and B, and CDC funds, among others. Expanded integration efforts included development of prevention with positives programs at Ryan White funded medical clinics which previously only provided HIV medical care. AACO recognized its Ryan White funded ambulatory medical providers are seeing a large proportion of the HIV positive population. To support these providers, AACO recruited seven agencies to employ Comprehensive Referral and Counseling Services (CRCS) specialists. This effort was expanded, through a recent Request For Proposals, via a locally developed intervention, Sexuality with Education and Truth (SWEAT). SWEAT is a six-week, group level intervention for young MSM geared towards the reduction of HIV stigma, providing “medical home” or HIV care practice, safer sex negotiation, adherence, counseling/treatment education, engagement and re-engagement in the larger HIV/AIDS community in Philadelphia.

Key Partnerships in Local Government

In some ECHPP jurisdictions, broadening the involvement and support of local government offices helped create opportunities and provided momentum and visibility to new HIV prevention initiatives. Connections between the health department and other local government offices and officials provided links to local businesses, which were a source of support.

• Philadelphia Department of Public Health (PDPH), AIDS Activity Coordinating Office (AACO) has a longstanding working relationship with the Mayor’s office, who is an advocate for public health and health equity. Through weekly meetings, AACO kept the Deputy Mayor of Health and Opportunity, who is also Health Commissioner, informed of progress, new activities, and challenges so he could better coordinate departments within city government and respond to HIV prevention needs. The Mayor and Deputy Mayor maintained a high profile for HIV with public appearances at AACO events and supported AACO in the news media.
• The Georgia Department of Public Health (GA DPH) recognized during the planning phase that a number of government-sponsored bodies worked independently, and in some cases redundantly, to achieve a common goal. Therefore, it helped establish relationships among several work groups (e.g., Ryan White Part A and the Early Identification of Individuals with HIV/AIDS (EIIHA) work groups). This collaboration allowed GA DPH to identify gaps in HIV services in the Atlanta MSA. Another benefit has been sharing information about linkage and retention programs and protocols with HIV service providers. These work groups, along with other advisory groups, are working collaboratively to establish a common definition of successful linkage to care in order to improve coordination of activities in the Atlanta area.

Policies to Support HIV Prevention

Local and institutional policies and regulations can support or impede better HIV prevention and care. To be sustained, shifts in HIV prevention efforts as suggested by NHAS should be reinforced rather than undermined by existing policies and regulations. Although health departments often do not have sufficient staff resources to devote significant time to advance policy activities, there are often some that can be accomplished with less commitment of time and resources. ECHPP health departments benefited from a careful review of potential actions in this category, often resulting in manageable objectives that supported HIV prevention efforts.

• At the time ECHPP began in September 2010, advocates, policy makers, and legislators in Pennsylvania were in the process of modernizing the Commonwealth’s 22-year-old HIV testing law (State Act 148 of 1990). In anticipation of the improved law, Philadelphia Department of Public Health (PDPH) made formal plans for swiftly implementing education and programmatic changes consistent with the new law. The revised law (State Act 59) was enacted in July 2011 and took effect in September of the same year. Consequently, PDPH quickly scaled up routine HIV testing in clinical settings because of the new law’s more efficient consent and counseling procedures. Efforts included offers of technical assistance and mass distribution of notices about changes to the law to 4,000 primary care providers. Champions, clinicians who are influential leaders in their own HIV outpatient clinics and within the healthcare system, were also recruited as advocates to help promote routine screening in other outpatient settings.
• In order to reduce the proportion of HIV-positive persons who report having unprotected sex, the Philadelphia Department of Public Health (PDPH) sought to enhance targeted distribution of condoms to this population. PDPH added a requirement into its service provision contracts that all PDPH-funded medical and medical case management providers establish protocols for distributing condoms to HIV-positive clients. PDPH also began to require that data on condom distribution be included as part of the agencies’ regularly submitted program monitoring reports.
• Chicago Department of Public Health (CDPH) implemented a cross-departmental initiative to incorporate language supporting public health into the program goals of all new funding opportunities published by the city. As a result, the Division of STD/HIV/AIDS Public Policy and Programs was better positioned to ensure that city funding supported HIV prevention goals even when the focus of a program was directed towards other health outcomes. This activity is part of a broader public health agenda called Healthy Chicago which aligns with the National HIV/AIDS Strategy.

Use of Data to Improve Service Delivery

Improving the coordinated and strategic use of programmatic, clinical, and surveillance data can greatly support improved quality and timeliness of client services for HIV prevention. One such improvement is the creation of secure mechanisms by which databases can to talk to one another. Many of the ECHPP health departments made great progress in this effort, as described below.

• The DC s HAHSTA analyzed HIV service providers’ program data and sent each provider “report cards” of their own data. Most providers do not yet have the capacity to analyze their own data, but many indicated a desire to use the results of the analyses to gauge their own progress and improve their programs. Thus, the report cards served as an incentive for providers to report program data to the health department.
• The Houston Department of Health and Human Services (HDHHS) implemented an electronic client-level integrated prevention system (“ECLIPS”) to improve the health department’s capacity to collect and manage data to improve the delivery of HIV prevention and care services. Using ECLIPS, the health department rapidly and effectively managed multiple data feeds into a centralized data reporting system. ECLIPS then interfaced with the jurisdiction’s patient care data management system and with HIV/AIDS surveillance databases, enhancing and ensuring accurate and timely data exchange between the HIV Prevention and HIV/AIDS Surveillance programs. With data feeds of test results from the HDHHS central HIV testing laboratory, ten hospitals across Houston and automated verifications of HIV referrals and linkage to care visit completions from multiple health care providers in the Harris County care system, ECLIPS provided a critical platform for disease intervention specialists and other health department staff to quickly identify persons newly diagnosed and link them to care. The implementation of electronic lab reporting into ECLIPS enabled the health department to access HIV laboratory data with special emphasis on CD4 test and viral load detection test results from private and public laboratories in the jurisdiction, which greatly improved their ability to identify known HIV-positive persons who may have fallen out of care and needed support reengaging into care.
• Integrating electronic lab reporting into a large public hospital system such as the Parkland Health and Hospital System provided the Dallas Health Department with more complete and timely surveillance data (i.e., HIV testing results, CD4, viral load) than paper-based test result notifications. The Dallas Health Department now has the ability to receive laboratory reports automatically transmitted in real time, which has improved its ability to monitor data quality and oversee local surveillance and partner notification efforts. These enhanced processes and reporting efficiencies, in turn, have led to improvements in linkage, re-engagement, and retention in care among HIV-positive persons in the Dallas area.
• The Los Angeles County Health Department of Public Health, Division of HIV and STD Programs (DHSP) implemented an improved data collection system to track HIV testing services. This streamlined data collection system facilitated DHSP’s effort to coordinate evaluation activities across funding announcements and use surveillance data to track progress towards NHAS goals for HIV testing services.
• The San Francisco Department of Public Health established the Linkage Integration Navigation Comprehensive Services (LINCS) Program, which provided linkage to care and partner services for newly diagnosed individuals, and navigation for patients who have fallen out of care. To facilitate targeted and timely service delivery, LINCS partners developed a memorandum of understanding (MOU) outlining procedures for data matching of HIV testing and surveillance data. This MOU allowed LINCS to distinguish between new and known HIV-positive cases, and therefore target partner services resources to newly diagnosed individuals and their partners.

Coordinating an Expanded Prevention Portfolio

Implementing combination prevention is key to achieving the NHAS; therefore, the role of care and treatment is increasingly integrated with HIV prevention interventions and strategies. This raises issues around coordination and management of program activities across these domains.

A practical way to support better coordination is to improve communication and relationships between planning bodies for both HIV care and prevention. The relationships between these critical planning bodies vary across jurisdictions. Many ECHPP health departments made efforts to improve the level of cross-communication and coordination between them in the first year of implementation.

Additionally, every organization must discover its own best way to manage the large and diverse portfolio of activities inherent within the NHAS and its vision of collaborative, coordinated efforts across a diverse array of stakeholders who together pursue change across a broad front. Such a complex tangle of relationships, investments, and activities require adjustments to a health department’s operations, structure, priorities and resource allocations. ECHPP grantees implemented a variety of approaches to address these issues in a way that supported improved coordination.

• The Chicago Department of Public Health (CDPH) integrated multiple planning bodies into one. The newly chartered Chicago Area HIV Integrated Services Council (CAHISC) integrated planning for prevention, housing, and other treatment and care services. CAHISC was formed to increase coordination and collaborative use of data across prevention, care and treatment partners, and enhance CDPH’s use of data when setting programmatic goals and objectives.
• Although an HIV prevention and care work group existed in Maryland prior to ECHPP, the ECHPP process focused these collaboration efforts on specific strategies and measurable objectives to maximize the impact of HIV prevention and care services in Baltimore. The work group assessed and described the current level of implementation for HIV prevention and care services across funding sources, including data on program funding, activities, reach and outcomes. Through this process, the work group identified priority areas to increase coordination and integration of services along the HIV prevention and care continuum, such as increasing the coordination of CDC and Ryan White linkage-to-care activities, and enhancing the integration of risk assessment and risk-reduction counseling into ongoing HIV care and support services.
• The Florida State Department of Health managed its expanded HIV prevention portfolio of activities under ECHPP by deputizing a series of internal champions to take primary responsibility for implementing different sections of the final plan. These champions were responsible for ensuring progress was made towards the measurable objectives outlined in their section of the plan. They produced reports for the Department and served as key liaisons to the field.
• In order to improve coordination, San Francisco Department of Public Health (SFDPH) organized meetings around programmatic goals rather than particular funding streams. This approach maximized coordination and collaboration across SFDPH’s comprehensive portfolio of activities. A significant advantage of this type of focus was the ability to identify similar or overlapping programmatic goals when different language was used across funding streams.