WHITE HOUSE HIV/AIDS DIRECTOR MEETS WITH BEYOND AIDS DELEGATION, BEFORE LEAVING POSITION

Update: President Donald J. Trump did not fill the position of White House Director of National HIV/AIDS Policy in 2017, in effect allowing that office to die. Adding insult to injury, at the end of December, the Presidential Advisory Council on HIV/AIDS (on which two current Beyond AIDS Board members have served in the past) was disbanded by firing all of its members. Clearly, Trump does not consider HIV/AIDS to be an issue worthy of presidential attention, as did every other President since 1995.

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On December 13, 2013, Dr. Grant Colfax, White House Director of National HIV/AIDS Policy (ONAP, a part of the Domestic Planning Council), met with a 7-member Beyond AIDS delegation. The discussion took place at UCLA, immediately after Dr. Colfax delivered a lecture there on "National HIV/AIDS Strategy and the HIV Care Continuum Initiative. Dr. Colfax was the third ONAP Director to have met with Beyond AIDS, over the course of two Presidential Administrations. UCLA Professor Jeffrey Klausner, who was a former colleague of Colfax when they both worked at the San Francisco Department of Public Health, arranged the session.

ONAP Director Colfax lecturing at UCLA

The delegation members provided an introduction to the past accomplishments and future goals of Beyond AIDS, as well as individual introductions. Beyond AIDS expressed support for the President's HIV Care Continuum Initiative, which Dr. Colfax had developed for President Obama and which was issued in July 2013. The delegation also offered to help keep public discussion on national HIV/AIDS strategy focused on the HIV Continuum of Care.

 Hattis presents papers to Colfax

Dr. Colfax reiterated some of the epidemiological points he had expressed in his lecture, including the 9 current goals of the Initiative, noting that the key risk groups continue to be similar to ten years ago: young gay males, blacks, Latinos, and transgender females. The discussion included the recent focus on interrupting transmission, as can be achieved through effective treatment that suppresses the virus. Ron Hattis presented a collection of Beyond AIDS policy drafts and PowerPoint presentation files for Colfax's review.

Jean Davis described the gaps in training of providers and other leaders, left by reduced funding of AIDS Education Training Centers. Gary Richwald brought up linkages of treatment and prevention. 

(Clockwise around table, from front) Jean Davis, Peggy Flanary, 
Grant Colfax, Gary Richwald, Dennis Thompson

Dr. Klausner commented on a proposed recommendation that gay males be tested every 6 rather than 12 months. Klausner suggested that the frequency of testing should depend on their number of partners. Hattis suggested that all infected persons and their immediate partners could be considered as top risk groups deserving focused attention for interruption of transmission.

Grant Colfax, center, makes a point to delegation members (clockwise around table, from 
front) Jeffrey Klausner, Peggy Flanary, Gary Richwald, Dennis Thompson, and Leith States

Ron Hattis explained that Beyond AIDS hoped to contribute ideas during 2014, for the 2015 update of the National HIV/AIDS Strategy, and suggested that it could be organized around the HIV Care Continuum. Leith States, a new Fellow of Beyond AIDS' Foundation, who was part of the delegation, offered to assist with that project. Beyond AIDS was hoping to establish an ongoing communication with ONAP so as to have input during the planning process. However, Dr. Colfax indicated that work had not yet been started on a revision to the strategy.

Delegation with ONAP Director: (left to right) Jeffrey Klausner, Jean Davis, Ron Hattis, 
Grant Colfax, Dennis Thompson, Gary Richwald, Leith States, and Peggy Flanary

Only six days after the meeting, a White House official let it be known that Dr. Colfax would be leaving his position at ONAP on January 13, 2014. Unfortunately, this means that the personal relationships established in the Beyond AIDS meeting will not result in the establishment of an ongoing liaison with White House planning, and further contacts will need to be made with the next Director of ONAP.

MEDICARE COVERS HIV TESTING...BUT ONLY IF YOU USE THE RIGHT CODE (Z11.4 for ICD10, FORMERLY V73.89 for ICD9)! AND OTHER INSURANCE MAY USE DIFFERENT CODES...

(Updated 10/28/15 for ICD-10; original article 12/21/13))

We thought we had it all solved four years ago. On December 8, 2009, Medicare announced that it would start covering the cost of annual HIV screening for all beneficiaries regardless of age, diagnosis, or risk indication, at no cost to the patient.  (Click here to read the story behind the approval, including the testimony from Beyond AIDS to the Center for Medicare and Medicaid Services, or CMS.) One might assume that if a test is free and does not require a special diagnosis or risk as an indication, coverage should be approved regardless of what codes are entered for billing. But one would be wrong! That's not how government, healthcare, or insurance work.

Beyond AIDS had originally become involved in 2009 when a member on Medicare was billed $77 by a lab because HIV testing was not a covered benefit. Four years after Medicare agreed to cover HIV screening, the same thing happened, only this time the lab bill was $169! Knowing that the test was supposed to be covered, our member appealed and asked for an explanation. It turned out that the doctor had used the "wrong" ICD diagnostic code.

When the physician was told of the correct code (which we're revealing to you here), the billing was revised. However, the lab initially neglected to pass on the corrected code to Medicare, and instead began sending the patient threatening letters from its collection agency. Eventually, the charge for the test was cancelled, but the lack of transparency on the part of CMS, combined with high charges and negligence by the lab, had meanwhile resulted in a lot of avoidable stress.

The good news is that for right now, providers can use the information in this posting and enter ICD-10 code Z11.4, to assure coverage of a routine EIA screening test on a Medicare patient.

ICD-10 code Z11.4 is an encounter for HIV screening, which the provider should enter on the lab requisition, and may also bill if there is no other diagnosis for the visit (this was formerly V73.89 under ICD-9). If there is special high risk, the additional code Z72.89 should be added. Medicare's requirement for codes for patients not complaining of a specific risk factor for HIV is not publicized, and is very difficult for physicians to locate with Web searches. This makes the promise of coverage for screening of all beneficiaries almost meaningless for practical purposes.

There are other codes that providers will generally not need to include in billing. The HCPCS code G0432 (infectious agent antibody detection by EIA technique) identifies an ELISA (EIA) combined HIV-1 and 2. If it is a rapid test, the code is G0435 (infectious agent antibody detection by rapid antibody test). According to CMS publication ICN 006559, October 2015, appropriate HCPCS codes for an HIV screening test depend on technique used.

Since the start of the Affordable Care Act ("Obamacare") at the beginning of 2014, all medical insurance coverages affected by the law (not just Medicare) are required to cover HIV screening at no cost to patients. That requirement is based on a strong (Class A) recommendation for routine and universal HIV screening of all persons ages 15 to 65, by the U.S. Preventive Services Task Force (USPSTF), in April 2013.  In addition to HIV testing, a number of other preventive services, including tests, immunizations, and treatments, will be covered by all qualified insurance plans under the law, especially for women. Hopefully, each insurance plan will agree to use the same codes as Medicare for the free screening. If an insurance plan were to select its own obscure code for the coverage of HIV screening and for each of the other preventive tests, that would present a barrier to preventive screening.

Additional issues are raised by this experience. Our member was required to obtain the HIV test by a healthcare employer. The legality of such a requirement will not be dealt with here, but is problematic. The lab charge for a simple HIV antibody screening when insurance apparently does not apply was already exorbitant in 2009, and increased by 119% in just 4 years. So it's a good thing that the country is moving toward free, routine HIV screening. But the billing code requirements that are currently used in the U.S. are not going to make that a simple matter.

The take-home pearl here is that Medicare providers should use ICD-10 code Z11.4, and Medicare patients who want an HIV test should  pass that information on to providers to avoid getting big bills from labs. But that's just for Medicare, and it might even change in the future. This is only the tip of the iceberg, because different codes may be used by a myriad of insurance plans, and for other newly covered tests and procedures as well as HIV testing. Medical organizations and insurance plans should determine and publicize the ICD-10 codes that must be used for billing each of the newly covered preventive services under the Affordable Care Act. The Beyond AIDS Foundation will continue to follow this issue.

ELEMENTS FOR A NATIONAL STRATEGY ON REDUCING NEW HIV INFECTIONS

(Prepared with input from individual members of HIV Policy Working Group, HIV/AIDS Section, American Public Health Association, but not adopted as an APHA document; carried forward by the Beyond AIDS Foundation)

Non-highlighted text was approved in concept as a basis for further policy development, at the Annual Meeting of Beyond AIDS, 11/9/13. Additions in bold text and deletions in strikethrough have been proposed as update, 12/2/13. This draft is a work in progress, and should not be considered as final policy of Beyond AIDS.

For prevention of HIV infections, Beyond AIDS supports periodic updates to the 2010 National HIV/AIDS Strategy through progress reports, to integrate the concepts described in the President’s 2013 HIV Care Continuum Initiative. The next overall revision of the National AIDS Strategy (expected in 2015) should emphasize a central role for the care continuum, with the goals of achieving treatment as prevention as well as benefiting the health of persons living with HIV. This continuum, with public health enhancements as included in the outline below, should be promoted and supported with adequate public funding, and with a high emphasis on the rights, confidentiality, voluntary cooperation, and dignity of persons with HIV:

• Universal, routine, opt-out screening should be provided to adolescents and adults, as recommended by the Centers for Disease Control and Prevention (CDC), and by the U.S. Preventive Services Task Force (USPSTF). Screening methods and confirmation algorithms used should be selected from the latest recommended by CDC or by the National Institutes of Health (NIH).
• Risk assessment and effective prevention messages should be offered to all persons testing negative who can be accessed for such services, with availability of counseling, referrals, and repeat screening based on risk. Nucleic acid or antigen screening at the initial visit should be considered for those with very recent suspected exposure (such as partners of persons with detectable viral loads or persons who have very recently engaged in high risk sex), if these may detect early infections that have not yet produced antibodies.
•  Prompt and routine initial outreach services, consistently and adequately funded in all local jurisdictions nationwide, should be provided for all individuals confirmed as testing positive:

o   Linkage to care by healthcare providers who are knowledgeable about HIV management and prevention

o   Initial partner services by disease intervention or other public health specialists, or by properly trained healthcare personnel as permitted by law, to identify the most likely source partner and the most recently exposed partners, including confidential notification, counseling, and opt-out testing of possibly exposed individuals

• Maintenance of continuous HIV care, including integrated prevention measures, should be optimized by competent providers and support resources, including the following services:

o   Prompt offering and initiation of antiretroviral treatment, and assurance of continuous treatment availability, based on current guidelines and best practices

o   Proven strategies for maintaining tight adherence to antiretroviral regimens

o   Active community outreach to patients missing appointments, and closely tracked referrals to new sources of care for those who require a change in provider

o   Referrals to specialists, support groups, ADAP, case management cross-trained in prevention, substance abuse treatment, mental health services, housing, prevention with positives, and other programs (historically funded by the Ryan White CARE Act) as appropriate

o   Prevention messages fully incorporated into ongoing care and treatment, and provided with the best evidence-based approaches including:

o   Routine assessment and brief counseling during clinical visits, regarding sexual and drug-related behavior, with referrals as appropriate

o   Monitoring of treatment adherence, with simplification or adjustment of regimens as needed

o   Monitoring of viral load suppression, with resistance testing and adaptation of treatment when indicated, with the aim of achieving undetectable viral loads or lowest viral levels possible, to prevent transmission as well as the development of viral resistance

o   Use of surveillance data by public health departments to monitor adherence, retention, and viral suppression with follow-up that maintains strict confidentiality

o   Ongoing assessment about new partners, and referral (as above) or performance of follow-up partner services, including confidential notification, counseling, and opt-out testing for contacts

o   Other Prevention with Positives components, including accessible, available, and acceptable condom distribution; screening and treatment of other STDs, hepatitis B and C, and tuberculosis; prevention of mother-to-child transmission; reproductive health care; and referral to other services as needs arise during care

• Prophylactic use of antiretroviral medications by uninfected persons should gradually become less necessary with implementation of the above strategy.  and should be for clear and limited Its indications should be approved prioritized by CDC.  Pre-exposure prophylaxis should not be advocated as a substitute for condoms.  The efficacy of intra-exposure prophylaxis with various regimens for sero-negative partners of persons known to be infected and on treatment, e.g., if viral load is still detectable on treatment, or when condoms are refused or deferred to attempt pregnancy, should be intensively studied.

Beyond AIDS also supports population-based efforts to reduce risk-prone behaviors within high-risk communities. Such efforts include raising awareness of the issues surrounding HIV/AIDS, reducing stigma related to testing and treatment, mobilizing communities to take preventive actions, making condom distribution a structural intervention, and changing community norms about condom use.  These efforts also should incorporate prevention of other similarly-transmitted STDs and bloodborne pathogens (including hepatitis B and C), especially emphasizing the avoidance of unsafe sexual and drug/needle-related behavior. Education and screening should be utilized as an important means of detecting infected persons to initiate the HIV continuum of care.

For injection drug users, clean needles/syringes should be made available, including through pharmacies and private sector initiatives; but prevention of infections depends on keeping them clean and ultimately unused. Public health and other publicly funded efforts should emphasize disinfection and non-sharing of “works”; screening for HIV, hepatitis C, and hepatitis B; drug abuse prevention and treatment; education and counseling including group support; referrals as needed to health care, nutrition, and housing; and rehabilitation.

In the 2010 National HIV/AIDS Strategy, the three prevention steps were all targeted at populations (intensifying HIV prevention efforts in the communities where HIV is most heavily concentrated; expanding targeted efforts with evidence-based approaches, and educating all Americans about HIV and how to prevent it). While such efforts tend to be less efficient for prevention of HIV than the care continuum, which stops HIV transmission at the source, they remain valuable in preventing infection of persons unaware that they have HIV-infected partners, and in reducing transmission of other sexually transmitted diseases. Funding should be distributed to achieve the most cost-effective combinations and balances among such population-based strategies, and between them and the HIV care continuum.

Population-based programs should be culturally appropriate, and should include sexual health education across the lifespan. They should include efforts to change community norms relating to risk behaviors, which have proven to have high potential effectiveness, such as the A-B-C programs in Uganda and some other locations, and with community-level interventions in the US. All should utilize intensive outreach efforts and the use of social network referral programs and should emphasize screening, in order to initiate the care continuum as outlined above; including combined or coordinated screening for HIV and other similarly transmitted diseases.