# Presentation: 874706

## Creating an AI/AN HIV Collaborative:  A Telemedicine Initiative

- Marie Russell, M.D., MPH
- Acting Associate Director,
- Centers of Excellence
- Phoenix Indian Medical Center

## US Epidemiology *

- New Estimates*
- 1.7 million people with HIV/AIDS
- Incident cases ~ 55,000 – 60,000
- Transmission – largely MSM
- 2006: Incidence increased 14% among MSM and 10% among heterosexuals.
- Perinatal: ~100 cases /yr

- * CDC HIV/AIDS Surveillance Report 2006, Released Spring 2008

**Notes:**
This slide reflects the most current data released in spring of 2008 with information up through 2006.  Transmission is still largely MSM however, there are increases in both MSM and heterosexual transmission

## Slide 3

## AI/AN Epidemiology

- Ranked 3rd in _rates_ of HIV/AIDS diagnosis *
- Est. # living with HIV/AIDS roughly 3,000+.
- Most MSM/IDU combo of any ethnicity *
- Survey: AI/AN youth at higher risk (YBRS, BIA/CDC)
- Shortest time from AIDS diagnosis to death.
- About 220 new HIV/AIDS cases per year (IHS Data)

- * CDC HIV/AIDS Surveillance Report 2006, Released Spring 2008

**Notes:**
Although overall number is low, AI/AN rank 3rd in rates of HIV/AIDS diagnosis based on # per 100,000 after AA and Hispanics
Est # is 3000 because reporting states (only 33) put the number around 2200 and we know that does not include california.
The youth survey was completed by the BIA and youth are having sex earlier and with more partners
Shortest time from AIDS diagnosis to death (can only be two reasons)
	Getting less than optimal care (which we believe is not the case based on HIVQUAL standards and PIMC data)
	Patients present later in disease course often with an AIDS diagnosis

In our study at PIMC, 41% of cases presented with CD4 of < 200 and 21% had an OI at Diagnosis (I think you already have that paper).  Jeanne Bertolli at CDC (if you don't know her, I'd be happy to introduce you) has done a much more extensive evaluation of surveillance data.  The answer is probably best summarized as AIAN are as likely as other groups to be tested late suggesting that there is as much reason to believe that there are undetected cases in AIAN populations as in other populations.  

Based on epi from:
CDC HIV/AIDS Facts sheets released 7/2005. HIV/AIDS among AI/AN. Based on data from 33 states
3rd behind African American and Hispanic
However, the total number of people living in the USA with HIV/AIDS is thought to be between 1,039,000 and 1,185,0005. The discrepancy between these figures is due to several factors including:
confidential name-based reporting of HIV diagnoses has not yet been implemented in all states6 
anonymous tests, including home tests, are excluded from case reports 
one in every four people living with HIV has not even had their infection diagnosed, let alone reported.7 

## HIV/AIDS in the Indian Health Service

- Dedicated National HIV Principal Consultant
- “HIV/AIDS is a critical and growing health issue within our Native population......we must change the way we discuss HIV, change (and improve) the way we integrate HIV testing into our health services, and firmly establish our linkages and access to care.  Robert G. McSwain – Director Indian 							Health Service

## Minority Aids Initiative (MAI)

- The Minority AIDS Initiative provides critical funding that can be coordinated and utilized to advance HIV/AIDS prevention and mitigation efforts in the American Indian/Alaska Native (AI/AN) population
- Indian Health Service does not have a base budget assignment of Minority Health funds, thus no allocated amount comes directly to the agency
- Proposals are coordinated through the National HIV Principal Consultant with focus on building capacity within and collaborating with other HHS agencies on providing training, expanding services, increasing surveillance, infusing behavioral health initiatives, integrating traditional health service linkages, advancing information and technological enhancements and developing outreach to communities

## Objective of HIV/AIDS Telemedicine Support Network

- To expand the quality and availability of HIV/AIDS communication, training, support, and expert consultation through the use of telemedicine technology for health care providers in Indian Health Service, Tribal, and Urban (I/T/U)
- Improve communication between current health care providers and increase the number of and geographic location of providers who are able to deliver the highest quality health care to the widely disbursed and highly mobile AI/AN patient population living with HIV/AIDS

## Relation to HHS Strategic Plan

- Eliminate racial and ethnic health disparities
- Increase access to health services for AI/ANs
- Accelerate the development and use of an electronic health information infrastructure
- Supports the agency’s GPRA developmental indicator and HIV QUAL

## Telemedicine Platform

- Alaska Federal Health Care Access Network (AFHCAN)
- Demonstrated ability of server infrastructure outside of Alaska
- Previous purchase and installation of AFHCAN sever structure in Phoenix Area
- Previous purchase of AFHCAN equipment in other HIS/Tribal facilities outside of Alaska
- Proven successful in Indian health settings

## MAI 2008HIV Chronic Care Initiative

- Innovatively apply Chronic Care Model (CCM) framework to increase capacity to deliver quality care to AI/AN people infected with HIV
- Relation to MAI goals/objectives and Department Policy –
- Increase access of AI/AN to HIV prevention, care and treatment services
- Increase the number of HIV infected AI/AN individuals surviving 3 years after diagnosis with AIDS
- Support the IHS Chronic Care Initiative

## Slide 11

## Approach

- Goals / Objectives of specific project
- Understand and decrease variation in provision of HIV care among AI/AN
- Develop and spread accessibility to sustainable HIV care among AI/AN resulting in prevention, earlier diagnosis, and improved survival
- Methodology
- Develop assessment tool using the Assessing Chronic Illness Care Model
- Assist 4 I/T/U organizations who provide HIV care to perform self-assessment using the model
- Develop formal improvement collaborative
- Partnerships –I/T/U facilities, National IHS HIV program, IHS Director’s Improving Chronic Care Initiative (CCI), Institute for Healthcare Improvement (IHI)
- Technologies –Utilization of evidence based CCM tools, Web-Ex, and IHS HIV Management System (HMS)

## Justification

- Need / Relevance
- AI/AN with HIV/AIDS face unique barriers to care
- I/T/U facilities/providers may be most competent choice to provide culturally competent care, social support
- Significant variation in capacity/experience and resources exists within I/T/U facilities
- Infrastructure and framework must be built to decrease variation in capacity and increase sustainable access to care within I/T/U facilities
- Impact – Collaboration on national level

**Notes:**
Need /relevance of Project:
Involvement and relevance of the specific agency to the population affected
The relevance of the proposed program to the needs, priorities, and disparities of the population to be served. Proposal should demonstrate clear understanding of the nature and extent of the HIV/AIDS problem (epidemiology) and any pertinent geographic or demographic characteristics of the target population.
Impact - Level of potential impact of proposed project on local, regional, or national level.
Budget Justification – Proposal will be evaluated for realism and reasonableness. Do the described project activities substantiate the requested budget amount?  OR Is there adequate rationale/justification for the budget requested? 

## Closing Thoughts?

- For people with HIV, **ACCESS** to medical care and delivery of HAART single most important determinant of survival
- Developing a national collaborative framework and infrastructure utilizing telemedicine platform and based on Chronic Care Model will
- Increase access to HIV health services for AI/ANs
- Increase the number of AI/ANs surviving 3 years after a diagnosis of AIDS (MAI Part Measure)
- Reduce racial and ethnic health disparities

## HIV Telehealth and Chronic Care Management within IHS

- Contact us if you are interested in participating in the grant
- Marie Russell, MD, MPH, CDR USPHS
- _[marie.russell@ihs.gov](mailto:marie.russell@ihs.gov)_
- 602-263-1578
- Heather Huentelman, PharmD, BCPS, LT USPHS
- _[heather.huentelman@ihs.gov](mailto:heather.huentelman@ihs.gov)_
- 602-263-1200 x 2002