Tiffany West: The Role Of Local Health Departments

AIDS in 2012: The chief of strategic information on HIV/AIDS for the D.C. Department of Health tells Joanne Silberner that innovative tools and strategic spending can cut into DC’s epidemic. A transcript follows.

JOANNE SILBERNER:  Tiffany West, Washington D.C., has the highest prevalence of HIV in the country at 2.7 percent.  What kind of policies are you using to bring this down?

TIFFANY WEST:  Great question.  In 2006, DC was one of the first jurisdictions to implement the CDC guidelines for opt-out routine HIV screening in medical settings.  Since that time, we’ve increased our rate of publically funded testing by 303 percent.  Additionally, we are also partnering with some private sector organizations, like Gilead Sciences, and MAC AIDS Foundation to do some very innovative testing strategies.  Right now we’re funding organizations to do testing at our DMV, as well as our income maintenance centers.  Additionally, last year we implemented a policy—it’s called treatment on demand—where we are insuring that all citizens know that their HIV treatment is available and low cost or free of charge here in the District.  So we’re very much focused on ensuring that people not only know their HIV/AIDS status, but they are virally suppressed.

JOANNE SILBERNER:  How is the Department of Motor Vehicles project working?

TIFFANY WEST:  It’s working fabulously.  It was a demonstration project funded last year by Gilead Sciences.  We were very surprised and excited about not only the number of people who actually wanted to receive testing, but also the number of positives that we found through our DMV testing program.  Some of those positives were previously positive; however it was a fantastic opportunity for us to re-engage those people who were living with HIV into care and treatment.

JOANNE SILBERNER:  What would you like to do in DC in the future?

TIFFANY WEST:  What a great question.  I think that specifically from a policy standpoint, we want to expand our coverage of HIV testing and treatment.  There’s an important decision that will be made by the U.S. Public Health Service Task Force that will enable governments like the District to offer HIV screening and ensure that it’s payable by third-party billers.  So I think that from the health department’s standpoint, with those particular policies and a scale-up of the Affordable Care Act, we really want to go from provision of services to promotion of services.  Our new policy around ensuring that we have multiple entry points into care and treatment, focusing on health homes, medical homes to people living with HIV.  It’s critical and really addresses the need for people to be engaged in continuous care, as well as ensuring that they receive the support services needed in order to have the optimal health outcomes.  So we’re excited about the Affordable Care Act, as well as expanding our condom distribution program, which won an award last year, and our social-marketing program, that you can see displayed all over the city for the International Aids Conference.

JOANNE SILBERNER:  And when you talk about third-party billers, or trying to get third-party billers more involved, are you talking about insurers?

TIFFANY WEST:  Definitely.  In DC, we have a unique insurance structure where even prior to the Affordable Care Act, more than 91 percent of our residents are already covered by some sort of health insurance.  Currently, we spend about $1.5 million on HIV testing, about 80 percent which are conducted in clinical settings.  If we can facilitate a way or have policies that facilitate third-party reimbursement for not only our public insurance companies, but private insurance, we feel like we can redirect those resources to other needs within our prevention care treatment portfolio.

JOANNE SILBERNER:  What about once you find a case, contact tracing is used with other sexually transmitted diseases?  Is that, at all, in play here?

TIFFANY WEST:  We have our partner services program traditionally has been offered as a service.  However, when you look at best practices in other jurisdictions like Texas and Vermont, the process of partner services is one that is owned by health departments.  And so when we look at other STDs like syphilis elimination, or other STD programs, they’re very much focused on ensuring that people who test positive are provided with the resources that they need in order to confidentially inform their partners that they need to get tested for HIV.  So we’re very excited about the implementation of our CDC program collaboration and service integration grant that focuses on these expanded strategies across disease areas.

JOANNE SILBERNER:  So it wouldn’t be mandatory, but it would be encouraged?

TIFFANY WEST:  It would be encouraged.  We don’t want to have mandatory activities within our communication with people in the community.  However, we do feel like partner services is a critically important function of the health department.  Therefore, we want to take ownership of ensuring that people are confidentially and securely informed of their HIV status and provide that service through a variety of mechanisms to people who may be at risk for HIV.

JOANNE SILBERNER:  You’ve talked before about spending money wisely, particularly in talking about testing approaches.  Can you tell me a little about that?

TIFFANY WEST:  Well I think that specifically, when you look at our budget at the department of health for the HIV/AIDS program, we are funded through a variety of our federal grants, for about $85 million.  We also have broad-based health insurance coverage, as I mentioned previously.  So it’s really important for us to look at the national HIV/AIDS strategy and the 12 cities project, and redirect our resources to programs and policies that we know are effective.  This is very different from the portfolio of prevention care and treatment programs that may have been funded 5-10 years ago.  So the use of data and information – whether it’s from surveillance or program or even our financial information – bringing the information together and targeting directing resources to communities at need, grantees, who are doing well, I think is the next in implementation in not only the national HIV/AIDS strategy, but the Affordable Care Act as a whole.

JOANNE SILBERNER:  So, just adding the HIV test to a blood panel that you get when you go to the doctor, that’s better than doing it separately?

TIFFANY WEST:  Absolutely.  Specifically in the District, 85 percent of all of our testing is done in clinical settings.  Therefore, the rapid test kit, on average, is $19.  Adding an HIV test to a blood panel or a panel that’s already being run in a clinical setting, I believe is a $1.50.  So the cost savings are tremendous, just in doing some of that ground breaking infrastructure policy work that we can collaborate with clinical providers to do.  They’ve had great success at scaling that up in New York City health departments and we’re looking towards other models to help us move in that direction.

JOANNE SILBERNER:  Last question:  DC is in a lot of ways unique.  It’s a city without a state, there’s a large poor population, and there are disparities in access of care.  The lessons you’re learning here and the work that you’re doing here, could this work in other places?

TIFFANY WEST:  Absolutely.  DC, you’re right, is 8×8 square miles.  However, if you take other urban cities or other communities, such as the Bronx, which we are working collaboratively with on a research study, we know that social marketing and scalable interventions that target populations most at risk are universal.  Through the implementation of the 12 Cities Project, CDC has identified, recommended and required interventions for the 12 jurisdictions who have the highest HIV/AIDS rates in the country.  Through that project, we’ve learned best practices from a multitude of jurisdictions and we continue to share those best practices and hope to disseminate that information to medium and low morbidity states as well.

JOANNE SILBERNER:  Well thank you very much.

TIFFANY WEST:  Thank you.