USCA 2017 - Day Two: Providing Quality Care and Eliminating Transmission
Two sessions we attended today focused on the tremendous strides that are being made in the area of HIV care and treatment. The first covered ongoing work within Ryan White HIV/AIDS Programs (RWHAP) to improve the quality of HIV care. The second focused on viral suppression as a powerful deterrent to HIV transmission.
RWHAP and Quality Management
HIV care programs continue to improve because they track what they are doing, solicit and receive feedback, and use that information to make changes where needed or continue doing the things that are working well. It's called clinical quality management (CQM), and agencies funded by HRSA's RWHAP have been engaged in this process for several years.
More than 100 attendees learned about RWHAP CQM requirements and shared some ideas on their finer points in a morning workshop on Day Two of USCA 2017 titled "Clarifying RWHAP Clinical Quality Management Program Expectations." Leading the session were HRSA staffers Marlene Matosky and Susan Robilotto.
Discussants reviewed HRSA's Policy Clarification Notice (PCN) 15-02, fielded questions on quality issues, and identified several new technical assistance and training resources on quality management. Some highlights are presented below.
HRSA and Quality Management
Quality management issues are being handled at the HRSA HIV/AIDS Bureau (HAB) under a new Clinical and Quality Branch(CQB) within the Division of Policy and Data. Marlene Matosky is the Clinical CQB Chief and Susan Robilotto is Medical Officer for RWHAP State and Metropolitan Programs at the HRSA/HAB Division of State HIV/AIDS Programs. Four CQB staffers were at the workshop to lend their support and expertise to grant recipients.
Quality management requirements for RWHAP Parts A through D are outlined in Policy Clarification Notice (PCN) 15-02. An extensive set of FAQs accompanies PCN 15-02 and addresses many issues that grant recipients may be pondering.
HRSA HAB’s Performance Measure Portfolio presents the performance measures by category. HRSA is currently augmenting its performance measure topic sheets, which will be uploaded to the HRSA/HAB website and announced on the HRSA HAB Information Email.
New CQI TA
Technical assistance and training resources to support CQM programming have been delivered for well over a decade through the HRSA-funded National Quality Center (NQC). HRSA's cooperative agreement with NQC expired on June 30 this year and was replaced by a new effort called the Implementation Center for Quality Improvement (ICQI), also operating under the auspices of the New York State AIDS Institute.
The difference between the two initiatives:
- NQC focused on building CQM infrastructure
- ICQI will focus on implementing CQM methodologies and concepts as required by the RWHAP legislation. However, feedback on a program's CQM will continue to be available
NQC resources will soon transition to the TARGET Center under the new ICQI project.
HRSA project officers also deliver support to grant recipients as part of oversight of federal grants. HRSA email accounts for fielding quality management inquiries include CQM Questions and HAB Performance Measure Questions
A number of question and answer exchanges among presenters and attendees drilled into some specifics on conducting quality management work.
Summary of some of the exchanges:
- RWHAP subrecipients should be involved in CQM efforts.
- Some clients don't like to conduct patient satisfaction surveys for fear that negative comments will lead to cessation of services with poor ratings. Participation in such activities has been improved by, for example, clarifying with clients that less-than-positive feedback has no negative implications (the point is to improve programs) and by engaging clients in patient satisfaction surveys through committees or other methods.
- Various grant recipients have struggled to generate meaningful consumer involvement in CQM. Productive steps can take many forms, such as treating a waiting room Comment Box seriously as a means of garnering feedback. Have someone monitor it, act upon input, and provide feedback.
Viral Suppression and HIV Transmission
The venue for "Getting on the Same Page: Viral Suppression and HIV Transmission" was much smaller than the site of the Quality Management workshop but still managed to accommodate approximately 100 participants. This session, one of multiple SMAIF workshops, outlined data on the efficacy of viral suppression--to undetectable levels to be precise--on reducing the risk of HIV transmission. Many studies document the risk in terms like "negligible' or "very unlikely." Given such very low risk, a coalition of agencies has pursued a consensus statement and message that Undetectable = Untransmissible, or U=U. New York City, San Francisco, Washington, DC, and other U.S. locales are among the first adopters of U=U. Internationally, London and Paris are early advocates of this approach. Many national and local groups, and individuals, are also on board with U=U.
Undetectable Virus and Transmission Risk: What's the Message?
Richard Wolitski, Director of the Office of HIV/AIDS Policy, provided the federal perspective on full viral suppression and viral transmission. Wolitski reviewed data from three landmark studies--HPTN052, PARTNER, and Opposites Attract--which produced no evidence of sexually transmitted HIV among virally suppressed participants.
"This is truly an historic time," Wolitski said in reference to the HIV epidemic. He outlined ongoing work of the HHS Ad Hoc Viral Suppression Working Group, which is reviewing and consolidating the federal position on study findings on undetectable viral load and viral transmission risks. The working group is comprised of representatives from HRSA, CDC, and other HHS agencies. It’s a work in progress, said Woliski, but the data undoubtedly represent a "game changer" in HIV care and prevention. HHS work includes message testing and ongoing review of new scientific findings.
Do clients need to be told that there are zero known cases of HIV transmission when viral load is undetectable? What is the measure of undetectability (<200 copies/mL or <50 copies/mL)? Does undetectability have to be documented over a period of time?
One workshop participant offered his thoughts on what terms such as "low risk" or "negligible risk" might mean to clients. Wayne Smith, Founder and Director of Samaritan Ministry in Knoxville, Tennessee, agreed that U=U will be "life changing" in Knoxville as many clients served by his agency are quite isolated. Yes, U=U will help break down some of the barriers and stigma they face. However, Smith didn't think that clients necessarily needed to hear the words "zero risk" of transmission to see their lives change for the better.