Enhancing HIV Prevention and Care Through CAPUS and Other Demonstration Projects Aimed at Achieving National HIV/AIDS Strategy Goals,2010-2018

Despite advances in HIV prevention and treatment during the past decade, more than 39 000 HIV diagnoses were made in the United States in 2016. ¹ In addition, persistent disparities in HIV acquisition and care, particularly among men who have sex with men (MSM) and racial/ethnic minority groups, make it difficult to end HIV. To focus our nation’s efforts toward this goal, the first comprehensive National HIV/AIDS Strategy for the United States was released in July 2010 with 4 goals: (1) reduce new HIV infections, (2) increase access to care and improve health outcomes for people with HIV, (3) reduce HIV-related disparities and health inequities, and (4) achieve a more coordinated national response within the federal government and between the federal government and state, local, territorial, and tribal governments. ² In 2015, the National HIV/AIDS Strategy was updated and extended to 2020. ³ During the past 8 years, the National HIV/AIDS Strategy has helped focus HIV prevention and care research, programs, and community advocacy. This supplemental issue of Public Health Reports focuses on demonstration projects led or co-led by the Centers for Disease Control and Prevention’s (CDC’s) Division of HIV/AIDS Prevention and funded by the US Department of Health and Human Services (HHS) Secretary’s Minority AIDS Initiative Fund (SMAIF). These projects targeted HIV prevention and improving health outcomes among racial/ethnic minority populations disproportionately affected by HIV.

When the National HIV/AIDS Strategy was released in 2010, HHS and CDC announced the availability of funds for the first SMAIF demonstration project, the Enhanced Comprehensive HIV Prevention Planning (ECHPP) Project. This 3-year project supported the 12 municipalities in the United States and its territories with the highest prevalence of AIDS cases in 2007 (New York City; Los Angeles; Washington, DC; Chicago; Atlanta; Miami; Philadelphia; Houston; San Francisco; Baltimore; Dallas; and San Juan, Puerto Rico). The goal for these cities, which together accounted for 44% of AIDS cases in 2007, was to redesign programmatic efforts to achieve the goals of the National HIV/AIDS Strategy by implementing a high-impact approach to HIV prevention. ^4,5 CDC’s national resource allocation model at the time, which is a model that shows what allocation of resources will prevent the most cases of HIV, showed that more resources should be spent on HIV testing, prevention, and care services for people with HIV, and prevention services for populations at high risk, particularly gay, bisexual, and other MSM. ⁶ The 12 ECHPP Project grantees were tasked with shifting resources to priority geographic areas, populations, and interventions to have a greater effect on HIV incidence and health outcomes. Multiple federal agencies were involved in planning and implementing this $42.8 million project. The first grantee meeting included CDC, HHS, and federal colleagues from the Health Resources and Services Administration (HRSA), the Substance Abuse and Mental Health Services Administration (SAMHSA), and the National Institutes of Health (NIH).

At the same time, HHS launched the 12 Cities Project, which awarded $5 million to CDC, $5 million to HRSA, and $2.5 million to SAMHSA to incentivize broader collaborations among federal agencies, state and local governments, and private entities in the 12 ECHPP Project areas. ^7,8 Coordination was also enhanced within agencies. For example, CDC formed cross-branch collaborations among interventionists, surveillance staff members, evaluators, program specialists, communicators, and capacity-building specialists.

Three recent articles used evaluation data on processes and outcomes to capture initial results from the ECHPP Project and describe the changes CDC made to manage the SMAIF demonstration projects. ^{9 -11} One article described the innovative program evaluation approach necessitated by the various HIV funding streams beyond CDC and SMAIF of ECHPP Project grantees, which included using data from various agencies and sources to attempt to capture the effectiveness of ECHPP Project planning activities. ⁹ Starting with the ECHPP Project, CDC learned that each SMAIF demonstration project required a careful focus on implementing the most useful, feasible evaluation methods for that project. Another article reported on how health departments carefully planned shifts in their programs—particularly by integrating data from multiple sources, seeking broad input from partners, and using resource allocation modeling—and then implemented their plans. ¹⁰ A third article addressed increases in high-impact HIV prevention programs for populations disproportionately affected by HIV. ¹¹ Data indicated that HIV testing, condom distribution, and partner services increased for African American and Hispanic/Latino populations, thereby helping achieve a goal of implementing high-impact HIV prevention programs among the most affected populations.

In 9 of the 12 cities, NIH funded collaborations between researchers and health departments to assess and document how ECHPP Project grantees worked toward attaining National HIV/AIDS Strategy goals. ¹² Since then, NIH has funded similar collaborations in additional cities and has supported 3 Journal of Acquired Immune Deficiency Syndromes supplements to disseminate results. ^{12 -14}

After the launch of the ECHPP Project, CDC developed 3 more SMAIF demonstration projects in close collaboration with federal partners. Each project was characterized by multiyear funding to scale up high-impact HIV prevention activities for populations disproportionately affected by HIV.

In 2012, the Care and Prevention in the United States (CAPUS) Demonstration Project (hereinafter, CAPUS) provided $42.8 million to 8 state health departments for a 3-year project (CAPUS was granted a fourth year of implementation through a no-cost extension) focused on racial/ethnic minority populations to improve the health and engagement in care of people with HIV and their continuum-of-care outcomes (eg, linkage to care, retention or reengagement in care, prescription of antiretroviral treatment, and viral suppression). ¹⁵ Core activities focused on finding and treating people with HIV in a jurisdiction to improve personal health and decrease transmission risk. Activities included increased HIV prevention, testing, linkage, and retention and reengagement in care; enhanced patient navigation services for people with HIV; increased use of HIV surveillance data and data systems to locate people out of care or not virally suppressed; and development of strategies to address the most proximal social determinants of health affecting project goals related to HIV testing, linkage, and retention and reengagement in care. Staff members from multiple federal agencies with relevant programmatic interests and expertise, including HRSA, SAMHSA, and other HHS offices, were fully integrated into the CAPUS structure and served as key members of project management teams, beginning with the development of the funding opportunity announcement. ¹⁶ CAPUS had the most explicit focus on social determinants of health compared with other demonstration projects, which signaled an important direction for HIV prevention and care to begin addressing some of the social and structural factors found to be associated with HIV prevention and care outcomes. As described in this supplement, grantees were required to address social or structural factors that were found in their community to directly affect continuum-of-care outcomes for the populations most disproportionately affected by HIV. This work is particularly important today, considering the availability of antiretroviral therapy to treat people with HIV and prevent transmission, and preexposure prophylaxis (a daily medication to prevent HIV acquisition), because HIV-related disparities can be exacerbated if disproportionately affected populations have reduced access to and use of these biomedical strategies.

CDC’s 2014 SMAIF demonstration project—the 3-year (2014-2017) Partnerships for Care (P4C) project—took agency collaboration a step further, with a co-leadership structure in which funding was split between CDC ($7.7 million) and HRSA’s Bureau of Primary Health Care ($30 million). CDC funded 4 state health departments and HRSA funded 22 collaborating health centers in those states to increase routine HIV screening and improve continuum-of-care outcomes by providing HIV prevention and care services. ¹⁷ HRSA awarded an additional $3.3 million to a technical assistance contractor to help implement the project in health centers. Through these health centers, approximately 100 service sites were involved in P4C to provide routine HIV screening and points of service for HIV prevention and care in areas with populations disproportionately affected by HIV.

Building on experience from the ECHPP Project, CAPUS, and P4C, CDC established 2 new demonstration projects in 2015. The 4-year (2015-2019), $60.5 million SMAIF-funded Targeted Highly-Effective Interventions to Reverse the HIV Epidemic (THRIVE) project supports 7 state and local health department collaborations with community-based organizations, health care clinics and providers, behavioral health providers, and social service providers to develop comprehensive models of prevention, care, behavioral health, and social services for MSM of color with HIV or at risk for HIV acquisition. ¹⁸ THRIVE grantees must develop and provide comprehensive services (13 services for MSM at risk for HIV acquisition and 11 services for people with HIV). A parallel, $5.5 million funded effort provides training and technical assistance to THRIVE grantees for the required services.

CDC’s Project PrIDE (PreP Implementation, Data to Care and Evaluation) ¹⁹ demonstration projects, funded by CDC and SMAIF for more than $83 million during 3 years (2015-2018), support health departments in implementing 2 public health strategies to reduce new HIV infections among MSM and transgender people, particularly people of color: (1) preexposure prophylaxis (12 health departments) and (2) Data to Care (5 of the 12 health departments), which uses HIV surveillance and other data to identify people with HIV not in care and to link, engage, or reengage them in care. Project PrIDE represents an important step in cross-agency collaboration, because after funding this project, CDC and the NIH’s National Institute of Mental Health worked together to strengthen the lessons learned about preexposure prophylaxis implementation. The National Institute of Mental Health funded supplementary grants of up to $175 000 per applicant (subsequently awarded to 8 projects in 6 cities) for preexposure prophylaxis implementation research in collaboration with Project PrIDE health departments. ²⁰ Following the example from the ECHPP Project, this funding supported collaborations between researchers and health departments to address specific, well-focused, and public health–relevant research questions that could not be explored with CDC’s nonresearch funding.

Demonstration projects have helped to advance National HIV/AIDS Strategy goals by bridging the gap between research and practice and ensuring that advances in HIV prevention and care can be rapidly implemented, scaled, and targeted. In all activities, CDC’s Division of HIV/AIDS Prevention prioritizes HIV prevention efforts focused on activities, populations, and geographic areas that are likely to yield the greatest impact. Demonstration projects also have spurred greater collaborations that have led to structural shifts in how work is conducted between and within agencies. CDC routinely reaches out to federal partners to discuss research opportunities that might supplement programmatic efforts. And it is now a standard CDC practice to work with federal partners when funding health departments and to collaborate internally across program, surveillance, evaluation, communications, and research branches in managing health department activities. The issuance of a joint Integrated HIV Prevention and Care Plan Guidance ²¹ is an example of a collaboration between HRSA and CDC that resulted from these demonstration projects. This guidance assists governmental and nongovernmental stakeholders in jurisdictional HIV prevention and care planning to ensure that high-impact HIV prevention principles are followed and that services to improve health outcomes along the HIV care continuum are available. The HHS investment in HIV demonstration projects has provided broad support for National HIV/AIDS Strategy goals, generated rapid lessons learned for the field and relevant evaluation reports and peer-reviewed publications, strengthened capacity building and health department peer-to-peer interactions, and spurred new ideas for future demonstration projects.