In this edition of Policy Watch: NASTAD's Top 10 in 2014

Policy Watch

Volume 26, January 6, 2014
Policy Watch is a newsletter for state and territorial health department staff that provides updates, analysis and highlights on the impact of national politics on HIV and viral hepatitis programs. Please visit NASTAD’s website at for more information or contact Oscar Mairena or Emily McCloskey.

NASTAD's Top 10 Policy Issues to
Watch in 2014
  1. Shutdowns Are So Last Year: FY2014 and FY2015 Appropriations
  2. ACA Implementation: It’s a Marathon, not a Sprint
  3. Raising the Bars: The HIV Care/Treatment Continuum/Cascade
  4. What’s Hip with HIP? The Next Steps for High Impact Prevention
  5. A New Frontier: The Future of Ryan White and ADAP Funding
  6. Breaking the Silence: Addressing the Viral Hepatitis Epidemic among Young Persons who Inject Drugs
  7. Cure Research and the Pipeline
  8. Stigma, Criminalization and Public Health Practice
  9. The Leadership Shuffle: Transitions and Openings in Key Federal HIV and Viral Hepatitis Positions
  10. Who Will Keep Control? The Midterm Elections
  1. Shutdowns Are So Last Year: FY2014 and FY2015 Appropriations
With spending levels for FY2014 and FY2015 set by last year’s Bipartisan Budget Act of 2013, all focus this year will be on FY2014 and FY2015 appropriations. The House and Senate Appropriations Committees have received spending allocations and are working through conference negotiations to establish program spending levels for FY2014.  Assuming this process goes smoothly, FY2014 funding should be finalized by January 15 in time to prevent a government shutdown. However, whether the Labor, Health and Human Services, Education and Related Agencies (LHHS) bill will be part of a larger omnibus or a continuing resolution is still to be determined. NASTAD will continue to monitor FY2014 funding as the appropriations process comes to a close. Meanwhile, the President’s FY2015 Budget is expected to be late because of the delayed FY2014 process. Although the FY2015 spending levels are set, FY2015 will be the first appropriations cycle post Affordable Care Act (ACA) implementation. While Congress has until October 1 to appropriate funding for FY2015, the debt ceiling will be reached much sooner which could lead to another compromise. Given the proximity of October 1 to elections, however, we do not anticipate another shutdown showdown this year.

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  1. ACA Implementation: It’s a Marathon, not a Sprint
The ACA’s implementation may have been marred by glitches with the rollout of, but there have been significant improvements.  As the first full year of implementation begins, 2.1 million people have enrolled in plans through the marketplaces, more than 3.9 million people have been determined eligible for Medicaid and the Children’s Health Insurance Program and open enrollment will continue until March 31. Pre-existing Condition Insurance Plans were extended through the end of January. This year’s implementation focus will be on managing client transitions and ensuring uninterrupted care. Round two of open enrollment begins November 15.  For more information on the ACA implementation process, please see the Health Reform Watch and read the Health Reform blog posts.

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  1. Raising the Bars: The HIV Care/Treatment Continuum/Cascade
Aside from having gone through several iterations of a name, the HIV care continuum has certainly changed CDC and HRSA’s approach to HIV prevention, care and treatment. Last year, the White House Office of National AIDS Policy (ONAP) announced the HIV Care Continuum Initiative (the Initiative). In December, ONAP also released a report outlining the first recommendations and action steps for the Initiative. Within the report, and consistent with NASTAD’s recommendations last year, is a step for “providing information, resources and technical assistance to strengthen the delivery of services along the care continuum, particularly at the state and local levels.” As 2014 progresses, we expect CDC, HRSA and other HHS National HIV/AIDS Strategy (NHAS)-implementing agencies to continue to align to this paradigm shift for HIV prevention and care. NASTAD will continue to monitor the Initiative’s activities and any new names for the continuum.

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  1. What’s Hip with HIP? The Next Steps for High Impact Prevention
Since the release of the NHAS and PS12-1201, CDC has continued to promote High-Impact Prevention (HIP), using combinations of scientifically proven, cost-effective and scalable interventions targeted to the right populations in the right geographic areas. While CDC estimates the reallocation of funding is nearly 85% complete, the overall amount of funding available via PS12-1201 is less than had been anticipated due to sequestration and other sustained budget cuts. While all jurisdictions are feeling the impact of constrained resources, lower prevalence jurisdictions may experience this all the more acutely as funding for some begins to fall below the $750,000 threshold (the previous floor). At the close of last year, CDC released an MMWR detailing the failure to meet the needs of gay, bisexual and other men who have sex with men (MSM) in HIV prevention. Since the rollout of the first grants in line with HIP, the core health department HIV prevention grants, there have not been any new surveillance numbers because of lag-time in data. 2014 is the first year we expect to measure the true success of HIP when new figures for 2011 and 2012 are made public. The HIP model and the HIV care continuum provide many opportunities for making a significant dent in the epidemic, curbing the rate of new infections among MSM and using the HIV surveillance data feedback loop to improve health outcomes for people living with HIV and, thus, prevent new transmissions. Finally, CDC is expected to award new Capacity Building Assistance (CBA) grants in line with the HIP model later this year.

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  1. A New Frontier: The Future of Ryan White and ADAP Funding
AIDS Drug Assistance Programs (ADAPs) currently have no waitlists for the first time in over five years. States were able to clear waitlists with an influx of emergency relief funding (ERF) from the federal government and continued pricing stability from partnerships with manufacturers. With maintained increases in funding, 2014 could be a waitlist-free year. FY2014 will be the first fiscal year that appropriates funds to the Ryan White Program without an authorization. It is crucial that Congress continues to fund the Ryan White Program at high levels in FY2014 and FY2015. The Ryan White Program reauthorization continues to be in a holding pattern while the ACA is implemented. NASTAD and the broader HIV community are working with Congress on a reauthorization plan, but it is unlikely that Congress will take action on Ryan White Reauthorization in 2014.

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  1. Breaking the Silence: Addressing the Viral Hepatitis Epidemic among Young Persons who Inject Drugs
Recent alarming epidemiologic reports indicate a rise in HCV infection among young people throughout the country. Some jurisdictions have noted that the number of people ages 15 to 29 being diagnosed with HCV infection now exceeds the number of people diagnosed in all other age groups combined. The 2011 Action Plan for the Prevention, Care and Treatment of Viral Hepatitis (Action Plan) was the first-ever national roadmap to address viral hepatitis. The recommendations, however, only spanned through 2013. HHS announced last year that the Action Plan would be renewed to extend recommendations from 2014-2016. The “Action Plan 2.0” is expected to be released in the first quarter of this year. Additionally, last year, the Office of National Drug Control Policy (ONDCP) released a new National Drug Control Strategy that takes a more public health approach to drug control and substance use policy. ONDCP’s leadership will be instrumental in working with the Administration to “Break the Silence” on the viral hepatitis epidemic and strengthen our primary prevention efforts among persons who inject drugs, particularly those under age 29. For more on NASTAD’s viral hepatitis policy priorities, read our Policy Agenda.

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  1. Cure Research and the Pipeline
Exciting new drugs came out last year for treatment of chronic hepatitis C infection. Janssen’s Olysio (simeprevir) and Gilead’s Sovaldi (sofosbuvir) were both approved with high success rates. 2014 could bring even bigger news for HCV treatment as both Gilead and AbbVie have therapies in the pipeline with high success rates and shorter dosage periods that do not require the use of interferon. These all-oral treatments could attain approval as early as this year. Research is already underway examining optimization of treatment for HIV and viral hepatitis (e.g., dose reduction, reformulation and process chemistry).  This research could lead to new combinations, reduced side effects, longer acting formulations and lower overall drug costs. Additionally, on last year’s World AIDS Day, the President announced a redirection of $100 million within the National Institutes of Health (NIH) for a new HIV cure and vaccine research initiative. NASTAD will continue to monitor developments in the research pipeline and the work of the new HIV cure and vaccine research initiative.

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  1. Stigma, Criminalization and Public Health Practice
Last year, the Presidential Advisory Council on HIV/AIDS (PACHA) and the U.S. Conference of Mayors passed resolutions calling for repeal of HIV-specific criminal statutes and the REPEAL Act was introduced with bipartisan and bicameral support. Late last year, Congress passed the FY2014 National Defense Authorization Act (NDAA), the first piece of legislation that mentions HIV-specific discrimination. NDAA calls on the Department of Defense (DOD) to release a report on personnel practices related to HIV and hepatitis B, including discharge and disciplinary policies. With the expected release of CDC and the Department of Justice (DOJ) NHAS deliverables this year, momentum on this issue may continue. While not the only way of addressing stigma and discrimination faced by people living with and at risk of HIV, the modernization of HIV laws and policies may greatly improve our ability to meet the NHAS goals. A large part of NASTAD’s efforts to combat stigma is our technical assistance efforts with health departments. Last year we held a Stigma Summit for Black and Latino gay men/MSM focused on the impact of homophobia, racism, HIV-related and gender performance-related stigma on public health, prevention efforts and health outcomes. NASTAD will continue to expand these technical assistance efforts in hopes of helping health departments meet the NHAS goals of reducing stigma and discrimination.

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  1. The Leadership Shuffle: Transitions and Openings in Key Federal HIV and Viral Hepatitis Positions
Last year, Dr. Jonathan Mermin was named Director of CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Dr. Laura Cheever was appointed the Associate Administrator of the HRSA HIV/AIDS Bureau and Dr. Elinore McCance-Katz was named SAMHSA’s Chief Medical Director.  Change is afoot once again for the federal government’s HIV and viral hepatitis positions. ONAP’s Director Dr. Grant Colfax announced his departure and a replacement has not yet been named. Ambassador Eric Goosby, the United States Global AIDS Coordinator and head of the U.S. Department of State’s Office of Global Health Diplomacy left the position in November and also does not currently have a replacement. The CDC’s Divisions of HIV/AIDS Prevention, Adolescent and School Health and Tuberculosis Elimination are all being led by interim directors while the search processes continue for permanent directors.  The Housing Opportunities for Persons with AIDS (HOPWA) Program is also without an administrator. Finally, as President Obama’s second term continues, the White House and the Administration will also see new arrivals and departures. Most recently, John Podesta, a former President Clinton Chief of Staff, joined the White House as a special advisor.

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  1. Who Will Keep Control? The Midterm Elections
The Congressional midterm elections are in November and it seems that control of both the House of Representatives and the Senate is up for grabs. With Congress’ dismal approval rating, many traditional “safe” Congressional seats are now competitive. The midterm elections will affect the fall work schedule for Congress and could lead to further division between Democrats and Republicans. Last year’s Virginia gubernatorial election saw Terry McAuliffe (D) ascend as the winner signaling a change in party leadership in a key battleground state. Meanwhile, Governor Chris Christie (R) overwhelmingly kept his seat in New Jersey, bolstering his standing as a potential 2016 presidential candidate. With key Republican and Democratic Members of Congress already announcing their retirement, the winds of change may blow towards Congress’ two houses in 2014. Congressional and state-specific elections this year could have a significant impact on many issues that directly or indirectly affect our HIV and viral hepatitis prevention and care efforts, including Medicaid expansion, same-sex marriage, immigration reform and, of course, ACA.

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