1. Treatment as Prevention:
Still not the magic bullet
Jeffrey Levi, PhD
SYNChronicity Conference
April 20, 2012
Arlington, VA

2. Combination prevention, not magic
bullets
 Clinical (behavioral and biomedical; address
syndemics)
 Community context and mobilization
 Structural environment (stigma,
discrimination, social determinants)
 US preference for technology rather than
addressing context of risk behavior (shared belief
among public officials and in affected
communities)—yet Tx as Prev. is harm reduction

3. For treatment as prevention to
work: Change the Gardner cascade
 Increase testing
 Missed opportunities in clinical system
 Get people into care
 Siloed testing and treatment systems
 Keep people in care
 Keep people adherent to treatment

4. A new financing environment
 Our current system is siloed and loses people
along the way
 Health reform changes the context for all
programs
 Medicaid expansion, subsidized coverage
 New role for CDC and RW programs
 Rethink the system before rethought for us
 Start with the individual

5. HIV INTEGRATED SERVICES DELIVERY MODEL DEMONSTRATION
CDC CMS HRSA/Ryan
White
State Medicaid
CDC surveillance Agency ASO funded by
funding with RW/HRSA with
enhanced CMS
enhanced CMS
funding for QA using
comm. viral load
Coordinating Agency funding for high
(could vary by design – Clinical group, ASO, etc.) intensity cases
Public Health Dept. Intensive Case
Management and
Funding according Capitated Medical Care Related Support
to insurance status Program
Services
HIV Testing Services
Behavioral Health
Services
HIV “Prevention for Housing Support
Positives” (HUD/HOPWA)
Funding
SAMHSA
Services
and Patient
Referrals

6. Steps along the way…
 Testing integrated into clinical system
 Standard of care, reimbursement
 Mobilization of affected communities
 Address associated needs
 Sense of community, social determinants,
syndemics, health literacy, adherence
 ASOs become community health organizations
 HIV community health workers
 Financed with RW/CDC funds freed from clinical needs

7. A time for hard conversations
 What is the role of AIDS service
organizations in a reforming environment?
 What does “payer of last resort” mean in a
reforming environment?
 And reform is happening regardless of the
outcome of the ACA litigation/election
 What social/sexual norms do we promote?
How do we frame harm reduction?