CAPUS is a three-year cross-agency demonstration project led by CDC and aligned with the National HIV/AIDS Strategy with the primary goal of reducing HIV/AIDS-related morbidity and mortality among racial and ethnic minorities living in the United States. We plan to fund 6 to 9 of the 18 eligible health departments in the US. The primary goals of the project are to: (a) increase the proportion of racial and ethnic minorities with HIV who have diagnosed infection by expanding and improving HIV testing capacity, and (b) optimize linkage to, retention in, and re-engagement with care and prevention services for newly diagnosed and previously diagnosed racial and ethnic minorities with HIV. These two goals are to be achieved by addressing social, economic, clinical, and structural factors influencing HIV health outcomes.

The primary focus of CAPUS is on addressing the social determinants of health that are barriers to two very specific and crucial interventions (testing and linkage to/ retention in care). In contrast, the Enhanced Comprehensive HIV Prevention Planning and Implementation for Metropolitan Statistical Areas Most Affect by HIV/AIDS (ECHPP) FOA (PS11-1117) was focused on the 12 cities with the most cases of AIDS at the end of 2007. The purpose of ECHPP was for each jurisdiction to develop a comprehensive plan for all of their HIV resources and to implement a broad range of interventions; 14 required interventions and up to 10 additional recommended interventions (depending on their plan). Similarly, the recent large health department FOA (PS12-1201) for HIV prevention is focused on the entire broad range of interventions that a health department might implement in their jurisdiction. By focusing only on testing and linkage/retention, and by focusing on easing social and structural barriers to these two important interventions, the purpose of this FOA is very different – both more focused in terms of interventions, and broader in terms of trying to address some of the root causes of inequities that underlie persistent HIV transmission.

CAPUS also specifically stresses the importance of modifying health-care delivery and other prevention and care systems to work more efficiently across organizational boundaries, improving coordination among public and private sectors, and addressing key social and structural determinants that are barriers to achieving optimal health outcomes. This approach will ultimately have the greatest impact on reducing HIV-related morbidity, mortality, and health disparities. This project also will require grantees to evaluate systems, leverage existing resources and tools, and carefully utilize these new funds to obtain a greater return on public health investments that directly address the overarching goals of the project.

Health departments are uniquely positioned to take a leadership role in supporting the optimization of services across public, private, and community-based organizations to achieve objectives of increased identification of HIV infection, earlier entry to HIV care, and increased consistency of care. As a result, the CAPUS FOA supports a limited competition funding opportunity announcement for 18 eligible health departments located in the United States. An estimated six jurisdictions will be funded, with a maximum of nine. The health departments include: Alabama State Department of Public Health; California Department of Public Health; District of Columbia Department of Health; Florida State Department of Health; Georgia State Department of Public Health; Illinois Department of Public Health; Louisiana State Department of Health and Hospitals; Maryland State Department of Health and Mental Hygiene; Missouri Department of Health and Senior Services; Mississippi State Department of Health; North Carolina State Department of Health and Human Services; Ohio Department of Health; Pennsylvania Department of Health; Puerto Rico Health Department; South Carolina State Department of Health and Environmental Control; Tennessee State Department of Health; Texas Department of State Health Services; Virginia State Department of Health.

As both the National HIV/AIDS Strategy (NHAS) and DHAP’s Strategic Plan (2011-2015) note, in the face of increasingly constrained resources and a concentrated, inequitably distributed epidemic, HIV prevention funding must be allocated to those communities and regions that shoulder the greatest share of the national burden. In addition, reducing HIV-related health disparities is one of the three primary goals of the NHAS.

Because of the high HIV disease burden among racial and ethnic minority populations, the disproportionate rate of AIDS diagnoses and associated mortality, and the pervasive impact of social and structural determinants of health, CAPUS includes limited eligibility for funding 18 state or district health departments in the United States. The 18 jurisdictions were selected based upon meeting the following three criteria:

a. Burden of HIV disease. In line with the Secretary’s Minority AIDS Initiative Funding and the National HIV/AIDS Strategy’s focus on decreasing health disparities and maximizing reductions in national incidence and mortality, only jurisdictions with greater than 5,000 HIV cases among African Americans and Latinos were chosen.

b. Disproportionately affected areas. Second, only those jurisdictions that had an AIDS diagnosis rate of over 6 per 100,000 in 2010 were chosen. This focus on disproportionately affected geographic areas is consistent with the National HIV/AIDS Strategy’s focus on decreasing health disparities.

c. Social determinants of health. Third, only those jurisdictions with a teen birth rate over 25 per 1,000 were chosen. This indicator allowed a focus on jurisdictions with underlying social and economic factors that impede HIV prevention and care.

Eligibility criteria cut-points were selected to narrow the eligibility pool given anticipated funding levels and the broad systems-level requirements and activities outlined in the FOA. Additionally, limiting competition to the 18 selected health departments and including a tiered funding system increases the probability that an individual eligible applicant is competitive and receives funding.
 

Yes, grantees will be required to maximize the public health impact of the resources in which they invest to improve testing and linkage/retention/re-engagement outcomes by working with a number of public and private partnerships within areas of the jurisdiction with greatest need. Because there is not one approach that will work effectively to address the overarching goals of the project across all jurisdictions, grantees will be examining and evaluating prevention and care approaches that when combined and brought to scale in the right locations, have the greatest public health impact. These combined activities should also have the greatest potential to address the social and structural determinants of health that are known to create the most significant barriers to testing, linkage to, retention in, and re-engagement with care and prevention in the applicant’s jurisdiction. This framework acknowledges that prevention and care/treatment synergistically contribute to reducing HIV-related morbidity, mortality, and related health disparities among racial and ethnic minorities in the United States.

In keeping with the spirit and goals of the National HIV/AIDS Strategy (NHAS), and in recognition of the complex, interrelated, and multi-sectorial nature of these goals, a multi-agency federal partnership guided the development of the CAPUS FOA. The partnership includes: 1) the Centers for Disease Control and Prevention (CDC), Division of HIV/AIDS Prevention (lead agency), 2) the Department of Health and Human Services (HHS) (the Office of HIV/AIDS and Infectious Disease Policy (OHAIDP), the Office of Minority Health (OMH), and the Office on Women’s Health (OWH)), 3) the Health Resources and Services Administration (HRSA) (both the HIV/AIDS Bureau (HAB) and the Bureau of Primary Health Care (BPHC)), and 4) the Substance Abuse and Mental Health Services Administration) (SAMHSA). Together, this cross-agency federal partnership team will provide ongoing leadership during all phases of project implementation.

CAPUS includes approximately $14,184,912 of funding for Year 1 activities (FY2012). The total projected estimated funding for Years 1, 2 and 3 of the project is $44,184,912. Total estimated funding for Years 1, 2 and 3 is subject to availability of funds.

ITo balance funding between the 18 eligible health department jurisdictions, the health departments are divided into three tiers with higher, medium, and lower HIV morbidity. The tiers are defined at natural HIV prevalence cut-points (looking at data from the 2010 HIV Surveillance Report) for funding purposes:

• Tier 1: Applicants eligible for Tier 1 are limited to six eligible health departments with an HIV prevalence of at least 30,000 cases.
• Tier 2: Applicants eligible for Tier 2 are limited to six eligible health departments with an HIV prevalence of at least 16,000 cases but less than 30,000 cases.
• Tier 3: Applicants eligible for Tier 3 are limited to six eligible health departments with an HIV prevalence of at least 8,000 cases but less than 16,000 cases.

Up to 4 awards will be made within each tier, and a maximum of 9 total awards is anticipated. Each of the funding tiers has an approximate ceiling, average, and floor award level based upon the number of total awards and available funding. The following are approximate funding levels for Year 1 (FY2012):

• Floor of Individual Award Range: Tier 1= $2,500,000; Tier 2= $1,650,000; Tier 3= $1,000,000
• Approximate Average Award: Tier 1= $3,000,000; Tier 2= $2,000,000; Tier 3= $1,200,000
• Ceiling of Individual Award Range: Tier 1= $3,500,000; Tier 2= $2,350,000; Tier 3= $1,400,000

CAPUS is funded through the HHS Secretary’s Minority AIDS Initiative Fund and does not include federal funds appropriated through the Affordable Care Act Prevention and Public Health Fund.

Grantees must fund community-based organizations (e.g., AIDS service organizations, hospitals, clinics, federally qualified health centers (FQHCs), community health centers (CHCs), faith-based organizations, sororities, fraternities, and other non-profit organizations) within their jurisdiction using a minimum of 25% of the total award for the development of human capital, skills, partnerships, and infrastructure development, as appropriate, to implement the activities required by the funding opportunity announcement. A CBO must (1) be positioned to provide services directly to clients and (2) must be recognized by members of the community as credible health or social service providers. Colleges, universities, and research institutions do not qualify as CBOs. This however, does not preclude universities from being partners or otherwise involved in the demonstration project via agreements.

The Centers for Disease Control and Prevention, Division of HIV/AIDS Prevention will function as the lead agency; however the cross-agency federal partnership team will provide additional ongoing leadership and technical assistance to grantees during all phases of project implementation.

CAPUS is designed to increase the overall impact of prevention activities on HIV-related morbidity, mortality, and incidence by enhancing public health systems and processes that determine when in the course of their infections racial and ethnic minorities living with HIV are diagnosed; if and when racial and ethnic minorities diagnosed with HIV are linked to care; and whether HIV-positive individuals are effectively retained in care. Accordingly, program performance will primarily be assessed using impact and outcome measures that can be calculated using existing, HHS-supported data systems (e.g., HIV disease surveillance). Any additional community level or population based impact measures identified by the federal partners or the grantee will be collected using similarly extant data systems (e.g., the Ryan White Services Report) and in close collaboration with local HIV prevention programs and other federal partners. Guidance on program monitoring and evaluation (M&E) and performance measures will be provided by the federal partners on an ongoing basis throughout the project period.

Grantees will focus on developing and implementing a demonstration project to address the following goals: 1) increase the proportion of racial and ethnic minorities with HIV who have diagnosed infection by expanding and improving HIV testing capacity, and 2) optimize linkage to, retention in, and re-engagement with care, treatment, and prevention services for newly diagnosed and previously diagnosed racial and ethnic minorities with HIV. These two goals should be achieved by addressing social, economic, clinical, and structural factors influencing HIV health outcomes. Funded health departments must develop a work plan that includes a set of required components and any additional supplemental/optional components or other approaches the jurisdiction selects to help achieve the overarching goals of the project. Because there is not one approach that will work effectively to address the overarching goals of the project across all jurisdictions, grantees should examine and evaluate approaches that will, when combined, have the greatest public health impact.

Teen birth rate was selected because the cross-agency federal partnership team wanted to use a non-HIV specific indicator of social determinants of health to select eligible jurisdictions for the CAPUS FOA. However, grantees will not be required to affect change in the teen birth rate within the jurisdiction.