Enhanced Comprehensive HIV Prevention Planning and Implementation for Metropolitan Statistical Areas Most Affected by HIV/AIDS

Overview

The Enhanced Comprehensive HIV Prevention Planning (ECHPP) Project is a 3-year demonstration project funded by CDC’s Division of HIV/AIDS Prevention (DHAP) for the 12 municipalities with the highest number of people living with AIDS in the United States. As part of the response to the National HIV/AIDS Strategy (NHAS), the ECHPP project supports the 12 Cities Project which is directed by the Department of Health and Human Services (HHS). These two projects directly support NHAS goals by improving program planning and implementation to:

• Reduce new HIV infections
• Link people with HIV to care and treatment and improve health outcomes,
• Reduce HIV-related health disparities, and
• Achieve a more coordinated national response to the HIV epidemic in the United States.

Lessons learned from ECHPP will inform how CDC can best work with health departments, other US government agencies and communities to reach the NHAS goals across the country.

Grantees

The project aims to maximize the impact of HIV prevention in the 12 Metropolitan Statistical Areas (MSAs) with the highest AIDS prevalence in the United States. These 12 ECHPP MSAs represent 44% of the estimated AIDS cases in the United States (data through December 2007).

Phase 1 provided $11.6 million for enhanced planning and coordination followed by implementation (September 30, 2010-September 29, 2011). Phase 2 supports ongoing planning, coordination and data reporting as well as implementation for 2 years (September 30, 2011- September 29, 2013).  In year 1 of Phase 2, CDC awarded the grantees $19.6 million.

The 12 ECHPP grantees include state and territorial health departments (Georgia, Florida, Maryland, Texas, Puerto Rico, District of Columbia) and directly-funded local health departments (Los Angeles County, San Francisco, Chicago, Houston, New York City, Philadelphia).

2007 Rank	Metropolitan Statistical Area/Metropolitan Division	Dec. 2007 Est. AIDS Cases
1	New York Division	66,426
2	Los Angeles Division	24,727
3	Washington	15,696
4	Chicago Division	14,175
5	Atlanta-Sandy Springs-Marietta, GA	13,105
6	Miami Division	12,732
7	Philadelphia Division	12,469
8	Houston-Baytown-Sugar Land, TX	11,277
9	San Francisco Division	11,026
10	Baltimore-Towson, MD	10,301
11	Dallas Division	7,993
12	San Juan-Caguas-Guaynabo, PR	7,858

ECHPP Planning Process and Evaluation

The planning process for ECHPP required each grantee to conduct a situational analysis and consider the following: local resources; epidemiologic profiles; available efficacy, cost, and cost-effectiveness data for specific interventions and strategies; and priority areas from existing local plans. The grantees used these data to develop a set of goals, strategies, and specific objectives to achieve an optimal combination of prevention activities to reach NHAS goals.

Grantees varied in their specific approach and included community and partner input in different ways. They were encouraged to engage community members and other stakeholders to the extent possible given the accelerated timeline for the enhanced planning during the first 6 months of year 1. It is anticipated that grantees will have ongoing conversations with partners moving forward. Several sites have also incorporated mathematical modeling techniques to further inform decisions about optimal combinations of prevention activities.

Additionally, key evaluation questions were developed that addressed the process, outcome, and impact of ECHPP. CDC’s ECHPP evaluation goals are to:

1. Assess optimal combinations of approaches to HIV prevention, care and treatment activities within the ECHPP jurisdictions.
2. Use surveillance data to assess the impact of local prevention, care and treatment programs.
3. Track jurisdictions’ progress towards achieving NHAS goals utilizing a variety of data types and sources.
4. Conduct additional data collection activities to monitor and evaluate ECHPP implementation in select cities

Interventions/Strategies

ECHPP plans include up to three categories of interventions and public health strategies: (1) required, (2) recommended, and (3) innovative. These interventions and strategies span the continuum from HIV prevention to care and treatment. All interventions and/or public health strategies have an evidence base and are expected to be scaled and targeted within each jurisdiction based on the local epidemic, need, and resources while considering available cost-effectiveness and efficacy data.

• The 14 required interventions or public health strategies include the following:
  • Routine opt-out HIV testing in clinical settings
  • Targeted HIV testing in non-clinical settings
  • Nine strategies for prevention with persons living with HIV
    • Linkage to care
    • Promotion of retention or re-engagement in care
    • Provision of antiretroviral therapy consistent with current guidelines
    • Promotion of adherence to antiretroviral medications
    • STD screening
    • Prevention of perinatal transmission
    • Ongoing partner services
    • Behavioral risk screening and interventions to reduce HIV transmission risk
    • Linkage to other medical and social services
  • Condom distribution targeted to HIV-positive persons and persons at greatest risk of acquiring HIV infection
  • Provision of Post-Exposure Prophylaxis
  • Efforts to change existing structures, policies and regulations that pose barriers to optimal HIV prevention, care and treatment
  • The 10 “recommended to consider” interventions or public health strategies include the following:
    • Condom distribution for the general population
    • Targeted health communications or social marketing campaigns
    • Provider-delivered, evidence-based HIV prevention interventions
    • Community-level interventions
    • Behavioral risk screening and interventions for high-risk HIV-negative persons
    • Integrated hepatitis, TB, and STD testing, partner services, vaccination, and treatment
    • Targeted use of HIV and STD surveillance data to prioritize risk reduction counseling and partner services for persons with previously diagnosed HIV infection with a new STD diagnosis, and persons with a previous STD diagnosis who receive a new STD diagnosis
    • For HIV-negative persons at highest risk of acquiring HIV, broadened linkages to and provision of services for social factors impacting HIV incidence such as mental health, substance abuse, housing, safety/domestic violence, corrections, legal protections, income generation, and others
    • Brief alcohol screening and interventions for HIV-positive persons and HIV-negative persons at highest risk of acquiring HIV
    • Community mobilization to create environments that support HIV prevention
  • The “innovative” local interventions are new ideas that jurisdictions believe could have significant impact on NHAS goals locally.

ECHPP Team

The CDC ECHPP Project Team is a multi-disciplinary one of scientists and program consultants that include division leaders and representatives from most branches within DHAP. Representatives from other federal agencies support ECHPP as members of the ECHPP Cross-Agency Implementation Working Group. These federal agencies include:

• Health Resources and Services Administration (HRSA) (both the HIV/AIDS Bureau [HAB] and Bureau of Primary Health Care [BPHC]),
• Substance Abuse and Mental Health Services Administration (SAMHSA),
• Indian Health Service (IHS),
• National Institutes of Health (NIH),
• Health and Human Services (HHS)

The Working Group fosters coordination and collaboration across agencies and evaluates agency policies that may act as barriers to coordinated planning, implementation, delivery, and evaluation of HIV/AIDS services within the ECHPP jurisdictions.

ECHPP and 12-Cities Project

The 12-Cities Project, under the direction of the HHS, Office of the Assistant Secretary for Health (OASH), expands upon the foundation established by ECHPP and establishes a cross-agency approach to advance the goals of NHAS. The 12-Cities Project aims to find ways that the federal government can improve coordination across the broad range of HIV prevention, care and treatment activities to support reaching NHAS goals. HHS agencies engaged in the 12-Cities Project include CDC, Centers for Medicare and Medicaid Services (CMS), Department of Housing and Urban Development (HUD), HRSA, IHS, NIH, and SAMHSA.

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