Sustaining Services and Outbreak Response for HIV, Viral Hepatitis, STIs, and TB

Introduction

HIV, viral hepatitis, STIs, and TB substantially contribute to the infectious disease burden of the United States. Approximately 40,000 people receive an HIV diagnosis each year, reported STI cases exceed two million, and congenital syphilis rates have increased nearly 700% over the past decade. Viral hepatitis B and C remain leading causes of liver-related morbidity and mortality, and TB incidence remains elevated over pre-pandemic levels. These trends reflect a growing syndemic — the clustering and interaction of epidemics driven by shared contextual factors such as poverty, housing instability, and limited access to care. HIV, viral hepatitis, STIs, TB, and substance use often intersect, compounding risk and worsening health outcomes.

Building flexible infrastructure that can respond to outbreaks while sustaining routine prevention and care services is essential when health threats and social needs overlap and interact. New advances in prevention and treatment offer unprecedented opportunities to reduce transmission and move closer to long-standing elimination goals; however, health agencies are also navigating funding and workforce constraints as well as changing care delivery models that reshape how to access and sustain services. With thoughtful planning and strategic alignment of resources, state health agencies can expand access to care, reduce inefficiencies, prevent outbreaks, and accelerate progress toward achieving public health goals in their communities.

How to Use This Toolkit

This toolkit is designed to help state health agencies maintain and expand access to HIV, viral hepatitis, STI, and TB services. Use it to:

• Explore strategies: Review practical approaches to align funding, strengthen partnerships and service delivery, and optimize operations.
• Learn from examples: Draw inspiration from field-tested interventions and adaptable models.
• Assess opportunities: Identify areas to integrate and streamline prevention, testing, and treatment services.
• Plan and implement: Apply tools to strengthen quality programs, build partnerships, ensure continuity of care, and prevent outbreaks before they occur.

Aligning Funding

Funding for HIV, viral hepatitis, STI, and TB programs is increasingly complex. Braiding and layering funding streams is strategically coordinating funding sources to cover distinct but aligned needs, which helps agencies sustain essential services and reduce duplication while supporting a broad set of activities. Likewise, identifying alternative opportunities (e.g., leveraging state funds, building private-public partnerships, or engaging with philanthropic initiatives) ensures programs can continue providing services even when traditional mechanisms fluctuate. This allows agencies to maximize resources without compromising reporting or compliance — and, ultimately, remain flexible, resilient, and patient-centered in a rapidly changing landscape.

Integrate Programs and Staffing

A common challenge for public health agencies is overcoming program silos to integrate services and maximize capacity. Consider addressing this by creating integrated program structures and syndemic-specific positions, as demonstrated by New Hampshire.

Achieving program integration requires time and strong support from both staff and department leadership — especially when it comes to breaking down funding silos. Agencies must assess the distribution of federal funds for syndemic programs, develop innovative frameworks for funding cross-cutting activities and positions, and solicit support from finance teams to ensure the newly braided funds are expended in an allowable manner. Importantly, integration is an ongoing process. As funding streams and program priorities evolve, agencies must maintain a sustained commitment to coordination and flexibility to ensure integrated efforts remain effective and responsive to public health needs over time.

Steps to Start

1. Review how program funds are currently distributed across disease areas and activities.
2. Identify opportunities to integrate or align overlapping functions without duplicating services.
3. Coordinate with finance teams to ensure any braiding or layering complies with funding requirements.
4. Plan for implementation, including exploring integrated staffing models (e.g., Illinois, Georgia, and Tennessee).

Identify Alternative Funding Pathways

Federal dollars often form the backbone of services for HIV, viral hepatitis, STIs, and TB in the United States, while state and other resources fill gaps. State-level funding gives states the flexibility to take focused action on the priorities that matter most to their communities. However, the level of direct state budget support for these programs differs significantly by jurisdiction.

Steps to Start

In assessing alternative funding pathways for your jurisdiction, prioritize the following:

1. A comprehensive coalition of community partners: Align messaging, involve people with lived experience, and educate state leaders (e.g., legislators) about the importance of infectious disease prevention and treatment.
2. A strong, relevant, and visible case:
   • Connect with elected state leaders through briefing opportunities.
   • Have a defined budget paired with justification for funding levels.
   • Demonstrate departmental capacity to effectively deploy funds.
   • Frame the data around priorities (e.g., in Hawaii, presenting mortality data in the context of years of life and workforce capacity lost resonated).
3. Consistency: Engage partners early and often, don’t expect it to be an initial priority, and be prepared to play the long game.

Leverage New Funding Sources

States may consider leveraging new funding sources, such as opioid settlement funds or funds from the Rural Health Transformation Program, to address infectious disease consequences of the opioid epidemic and expand prevention, testing, treatment, and care for HIV, viral hepatitis, STIs, and TB linked to substance use.

Opioid settlement dollars can help strengthen cross-cutting public health infrastructure and strategies to reduce the spread of infectious diseases, as demonstrated by Arizona, New Jersey, and Minnesota. Expanding access to testing, increasing linkage to care, and financing pharmaceutical treatments are just a few of the ways that states have used these funds. Complementing these efforts, the Rural Health Transformation Program offers a flexible mechanism for integrating substance use and infectious disease services in rural communities through system redesign and coordinated investments. Relevant uses of funds under this program may include recruiting clinical workforce to rural areas, supporting opioid use disorder treatment services, and developing innovative models of care to better reach rural communities.

Steps to Start

To get started with this strategy, review allowable uses, mapping each funding source to state prevention priorities for HIV, viral hepatitis, STIs, TB, and substance use. Then, engage relevant stakeholders —identifying gaps, opportunities, and collaborative strategies that support integrated prevention, treatment, and outbreak response.

Strengthening Partnerships and Service Delivery

Strengthening partnerships and integrating service delivery models can help align efforts across systems, improve referral pathways, and reduce fragmentation in care. This may include leveraging community-based outreach, formalizing cross-sector collaborations, and enhancing care coordination models to ensure individuals can access timely, comprehensive, and responsive services—ultimately expanding capacity, reducing bottlenecks, and improving access.

Coordinate Interjurisdictional and Nontraditional Partnerships

Addressing the syndemic of HIV, viral hepatitis, STIs, TB, and substance use requires state and local health departments to work in close coordination with community partners, ensuring policy, resources, and data systems are connected to respond in real time to related epidemics — as illustrated by Kansas.

Steps to Start

1. Identify and map partners: Work with organizations, community networks, and local health departments to guide outreach and support coordinated syndemic response efforts before, during, and after outbreaks.
2. Build meaning into each role: Establish convenings, joint workgroups, or peer learning networks to give community members and partners a meaningful role in shaping response efforts.
3. Sustain trust for long-term impact: Maintain ongoing collaboration with trusted organizations to reinforce community trust, strengthen systems for future outbreaks, and support a sustainable, coordinated response framework.

Integrate Service Delivery

Integrated service delivery responds to overlapping conditions and shared drivers of health, leading to better health outcomes, reduced system burden, and higher quality care for affected populations.

Steps to Start

1. Map existing funding streams: Identify federal, state, and Medicaid dollars that can be braided together to sustain services. Ensure eligibility covers opioid and co-occurring substance use disorders from the start to avoid reimbursement barriers.
2. Invest in workforce training: Provide nurses and primary care providers with targeted training and technical assistance to identify and respond to co-occurring substance use, mental health, and infectious disease conditions.
3. Start small and scale: Partner with federally qualified or community health centers already serving the intended populations to pilot and refine the model before expanding statewide.

Optimizing Operations

Streamlining processes and improving workflow efficiency is critical for ensuring that essential health services reach those who need them most. By optimizing operations, programs can maintain continuity of care, free up staff time, make the best use of available resources, and respond more effectively to evolving needs.

Upgrade Electronic Workflows

Streamlining processes focuses on embedding new interventions into existing workflows to improve efficiency, reduce staff burden, and strengthen continuity of care. In syndemic prevention, care, and outbreak response, operational optimization of case management systems is especially important for scaling screening and linkage efforts without requiring additional standalone processes or resources.

Steps to Start

1. Identify the need: Use local surveillance data to pinpoint disproportionately impacted populations and screening gaps in key care settings.
2. Automate testing: Embed electronic health record-based algorithms that trigger appropriate tests within existing workflows.
3. Leverage existing systems: Enhance opt-out screening and/or point-of-care testing in high-volume settings (e.g., emergency departments, correctional facilities, etc.) rather than creating separate programs.
4. Link and refine: Ensure linkage to care for those that test positive and refine algorithms based on outcomes and workflow performance.

Integrate Surveillance and Data Systems

Integrating surveillance and data systems enables jurisdictions to identify patterns, improve coordination across programs, and translate data into more targeted and effective public health action. By breaking down data silos, health departments can better understand co-morbidities, streamline reporting, and strengthen cross-program response capacity.

Steps to Start

1. Build the foundation: Align on shared syndemic priorities, inventory existing data systems, and begin planning for integrated governance, data sharing, and cross-training.
2. Integrate systems and teams: Integrating surveillance systems across programs can be challenging, particularly when agencies rely on legacy systems or differing data standards. Jurisdictions can start by mapping data flows, identifying interoperability gaps, and establishing shared standards. Working with vendors or internal IT teams to enable integration through standardized formats or shared platforms and cross-training staff across conditions can further support coordinated investigations and use of integrated data.
3. Act on the data: Use integrated data to identify co-morbidities, streamline reporting, target interventions, and inform program and policy decisions. Consider data visualization tools to identify trends and better communicate complicated epidemiological data.

Additional Strategies

Additional forward-looking strategies can help to maintain and expand access to prevention and care for HIV, viral hepatitis, STIs, and TB, including:

• Timely, interoperable data systems to identify overlapping risks, geographic hotspots, and service gaps. Integrating surveillance, laboratory, and program data can improve prevention, testing, treatment, and linkage-to-care services. Data modernization efforts should prioritize cross-condition analytics and real-time dashboards to support efficient resource deployment and evaluation across interconnected epidemics.
• Outbreak readiness with coordinated planning that anticipates how infectious diseases and substance use trends may amplify one another. Jurisdictions can strengthen readiness by cross-training staff, aligning response protocols across programs, and building surge capacity for integrated testing, treatment, and care during public health emergencies. Embedding syndemic principles into emergency operations plans supports rapid, coordinated responses that address both immediate threats and underlying vulnerabilities.
• Supportive policies that align funding streams, reduce administrative silos, and support integrated service delivery support sustainable syndemic responses. States and localities may consider expanding provider scope-of-practice authorities and standing orders to increase access to testing, treatment, and prevention services, particularly in care shortage areas. Jurisdictional leaders may consider enhancing the uptake of long-acting medications (e.g., long-acting injectable PrEP) and other therapies (e.g., DoxyPEP) by ensuring clear coverage and adequate reimbursement rates across Medicaid and commercial insurance plans. Aligning payment policies and incentives with integrated care models can further promote coordinated, patient-centered services across syndemic conditions.

Conclusion

Sustained progress across HIV, viral hepatitis, STIs, TB, and substance use will depend on deliberate alignment of strategy, financing, workforce, and operations. The approaches outlined in this toolkit are intended to help jurisdictions move from parallel efforts to coordinated implementation — using data to guide decisions, preparing for complex outbreaks, and modernizing service delivery structures to support integrated care. By institutionalizing these practices, health departments can strengthen resilience, improve efficiency, and better position their systems to meet both current demands and emerging challenges.

Additional Resources

Reviewed by Meredith Allen, DrPH, MS, Vice President, Health Security; Kate Petersen, MPH, Senior Director, Infectious Disease Infrastructure & Policy; Geetika Nadkarni, MPH, Director, Chronic Infectious Diseases; Amelia Poulin-Obregon, MPH, Assistant Director, Emerging Infectious Disease.