With about $200,000 in its pocket and an application for $2 million in the pipeline, Arkansas' plans under a decadelong federal effort to stop new HIV infections are taking shape.
Almost a year into the initiative, state officials say they're laying groundwork, setting goals that focus in part on improved access to treatment.
President Donald Trump announced the "Ending the HIV Epidemic: A Plan for America" program during last February's State of the Union address. By targeting 48 "hot spot" counties and seven states with high rural HIV burdens -- including Arkansas -- the program aims to cut new HIV transmissions in the U.S. by 90% by 2030.
Tiffany Vance, infectious disease branch chief for the Arkansas Department of Health, said that since the project's unveiling, state officials have been "in our conference room day in and day out" to brainstorm and write up funding applications, though some of what's to come remains unclear.
"We probably have a little bit more detail now than when [the federal initiative] was first announced, but still at the same time, I think we end up asking questions," Vance said.
"Even with the funding and the proposals and everything we have submitted, it's still honestly just waiting to see if everything will be truly, fully funded."
About 6,200 Arkansans -- or a little more than 200 of every 100,000 individuals -- had HIV or AIDS at the end of 2017, according to Health Department data. The state has the nation's 20th-highest rate of new HIV diagnoses.
After the national program's rollout, a $199,738 award from the federal Centers for Disease Control and Prevention was disbursed to Arkansas in September, and word on a $2 million award from another agency is expected soon, Vance said.
Discussing what they're looking at and how federal funds will be used, Vance and department HIV specialist Jon Allen said state officials are working to engage providers and the public to assess HIV knowledge and get feedback.
Listening sessions for both groups are planned around the state for this spring, with an eye toward gathering input from doctors and community providers to boost HIV treatment in primary-care settings.
New therapies make HIV care by family practice doctors possible, Allen said. Today, people with HIV are less likely to develop complications and don't have to be treated by specialists, of whom there aren't very many.
Other goals outlined in plans submitted to federal health agencies include making testing widespread and connecting people who test positive for HIV to treatment quickly -- perhaps as soon as the same day.
That could be supported by new workers, officials said. Specialized workers would connect newly diagnosed people with treatment and support programs, manage logistical hurdles such as transportation and reconnect dropouts with care.
Arkansas is not exempt from a national problem in which lots of people with HIV aren't in treatment at all, Allen said. That's important because viral suppression through medication makes it unlikely that a person will pass the disease to a partner.
One piece that isn't fleshed out is the Health Department's role in offering pre-exposure prophylaxis medication, which will become available to at-risk uninsured people for free through a separate federal program announced last month.
Vance said officials have discussed how the state agency might take part in that distribution, but they're still talking it over. Local health units don't now prescribe the drug that can prevent HIV.
As they plan, officials are prioritizing input from people living with HIV and AIDS about what would be most useful, an approach that Vance said federal public health groups encourage.
For example, officials once learned from patients that Walmart gift cards given out as incentives at outreach events aren't as useful as Dollar General cards, as the smaller stores are easier to travel to in some areas of Arkansas.
"That's the whole idea," Allen said. "The things that we've been doing and the way that we've been doing them have not been working, and we need to find a way to reach people where they are."
'BETTER LATE THAN NEVER'
Reams of internal Health Department documents obtained through an Arkansas Freedom of Information Act request show intensive meeting schedules, information-gathering and enthusiasm about the "Ending the HIV Epidemic" plan.
Just after the federal program's announcement in February, Dr. Naveen Patil, medical director for the infectious disease branch of the state Health Department, hailed the development in a note to the agency's leader, Secretary of Health Dr. Nathaniel Smith.
"Plans we discussed almost 10 years ago when I joined [the department are] now seeing light, its better late than never," he wrote. "I am so happy to be part of this process to see elimination of a disease in the near future."
Over the past year, high-level officials including CDC Director Dr. Robert Redfield and a national expert on HIV dental care have visited Arkansas to discuss its plans, and a minority-group health office was reorganized as the Office of Health Equity and HIV Elimination in November.
Several work groups including a task force of providers, pharmacies, advocates, insurers and government representatives also met throughout the year. Their meeting minutes, unrelated emails, draft plans and other records show dozens of ideas, including:
• Adding various HIV-specific staff members with a variety of proposed duties, including simple tasks such as helping patients pick up medications.
• Creating a task force to study syringe exchange programs (currently prohibited in Arkansas).
• Improving outreach by care liaisons to groups disproportionately affected by HIV, such as black, Hispanic, transgender and gay Arkansans.
• Expanding testing through diverse sites, potentially including pharmacies, colleges, nonprofits and food banks.
• Initiating sensitivity training for providers and workers who have direct contact with patients.
A recurring theme is the leveraging of partnerships. In one email, Patil floats the idea of emergency departments screening high-risk patients for HIV; in another, Chief Medical Officer Dr. Gary Wheeler proposes hosting a roundtable at a Little Rock church.
"We need to defeat religious prejudice if we want to win this war," Wheeler wrote.
Minutes from the task force's meetings also include remarks from HIV patients detailing struggles while navigating treatment in Arkansas, often dealing with fear of others' judgment.
One woman who was diagnosed with HIV in 2015 told the group that she'd almost lost her job because her medication upset her stomach, but she hadn't wanted to tell her employer why she was sick.
Elimination of HIV would mean being "free to live without worrying about meds, from having to tell someone she is dating she lives with HIV, from stigma, from it affecting her family and friends, from not wanting to face the public," the patient said, according to the minutes.
'HIV 101 AND 201'
Local advocates who work on HIV and AIDS issues say they're encouraged by the direction of the state's work under the "Ending the HIV Epidemic" plan, but there has been a learning curve for some involved.
Cornelius Mabin, CEO of the health nonprofit Arkansas RAPPS and co-chairman of a Health Department group on HIV prevention, said stakeholders at some meetings including the task force seemed unfamiliar with the federal program and the needs of HIV-vulnerable groups, such as people who are transgender or sex workers.
"Many people who have come to these meetings, they're hearing verbiage ... about scenarios that I don't think they have thought about," he said. "It's like, yeah, [transgender health] is a part of this discussion."
The knowledge base among meeting participants has gotten better as time has gone on, Mabin added. He agreed that education for doctors who are "not quite up to speed with where we are now" should be among priorities.
In an undated letter to Health Department officials released to the newspaper, Diedra Levi wrote that task force meetings were "providing HIV 101 and 201 to people with power" and that they needed to change direction to be more effective.
"We are losing valuable time. ... If these new funds are used on old methods, what's the point?" wrote Levi, who oversees a housing program for people with AIDS in Faulkner County.
Reached this month, Levi said she now feels better about the group, adding in an email that "there have been innovative strategies offered for implementation. It's clear that the time is now."
Meetings of the task force are for people with "an array of experience ranging from very little to expert," Arkansas Department of Health spokeswoman Danyelle McNeill wrote in an email.
"Anyone is welcome to participate by listening, sharing and providing innovative ideas to end the epidemic in Arkansas. Our goal is to facilitate open discussions in a safe environment."
OTHER STATES AT WORK
As their plans come together, Arkansas officials are working in parallel with health authorities in Oklahoma, Missouri, Kentucky, Mississippi, Alabama and South Carolina, all of which are targets of the federal program.
Each state was identified as having 10% or more of its new HIV cases in rural areas, according to U.S. Department of Health and Human Services materials.
In two of those states, health officials said they have been hard at work on their plans over the past year.
In Oklahoma, where a comparable number of people to Arkansas have HIV or AIDS, health officials are coming up with ways to improve access to care for people who live in areas like the state's panhandle, hours away from the closest infectious-disease specialists, said Sally Bouse, administrative programs manager over prevention and intervention.
They will watch the upcoming Oklahoma legislative session for movement on legalizing syringe exchange programs, which could be incorporated in their work, she said.
Overall, Bouse felt the federal initiative has raised interest in collaborating on HIV work. Groups that "we haven't been able to get to the table before are really getting involved in this issue," she said.
At the Missouri Department of Health and Senior Services, Bureau of HIV, STD and Hepatitis chief Christine Smith said the state received some federal "Ending the HIV Epidemic" funding already and has applied for more.
More than 12,000 people now live with HIV and AIDS in Missouri, and officials there want to fold in people who do not know they have HIV, who are newly diagnosed, who are disconnected from care or who are not virally suppressed.
Smith said officials have been strongly encouraged to "be innovative," so they have included approaches in their draft plans that haven't been tried before because of funding restrictions or staff capacity.
"What opportunity [do] we have to be effective?" she said. "We're starting to think outside the box a little bit more."
A Section on 01/13/2020
Print Headline: Arkansas maps out its efforts on HIV