Public Comments on the 60-day FRN

August 3, 2020
Jeffrey M. Zirger
Information Collection Review Office
Centers for Disease Control and Prevention
1600 Clifton Road NE
MS-D74
Atlanta, Georgia 30329
Reference: Medical Monitoring Project Facility Survey
Dear Mr. Zirger,
The Academy of Nutrition and Dietetics (the “Academy”) appreciates the opportunity to submit
these comments to the United States Preventive Services Task Force relative to its June 2, 2020
request for comment on the information collection: Medical Monitoring Project Facility Survey.
Representing more than 107,000 registered dietitian nutritionists (RDNs),1 nutrition and dietetics
practitioners, registered, and advanced-degree nutritionists, the Academy is the largest
association of food and nutrition professionals in the world and is committed to a vision of the
world where all people thrive through the transformative power of food and nutrition and related
support systems. Every day our members provide medical nutrition therapy for patients with
many diagnoses, including HIV and AIDS.
The Academy supports this survey of the characteristics of HIV care facilities in order to
assess the nation's existing HIV care infrastructure and the capacity to implement the
strategies of the Ending the HIV Epidemic Federal Initiative. We offer the below comments
and suggestions to enhance the utility of the planned survey and improve sensitivity to
health disparities.
I.

Section I: General Characteristics

In the list of options for the respondent to describe the facility, notably missing are Indian Health
Service Health Centers, Tribal Health Centers, and Urban Indian Health Centers. According to
prior MMP surveillance reports, American Indians/Alaskan Natives (AI/AN) have the fourth
highest HIV infection diagnosis rates among all racial and ethnic groups, yet little has been
published about the impact of HIV in this population.2 AI/AN people living with HIV experience
high levels of poverty, depression, HIV-related stigma3 and have lower viral suppression rates

The Academy approved the optional use of the credential “registered dietitian nutritionist (RDN)” by
“registered dietitians (RDs)” to more accurately convey who they are and what they do as the nation’s food
and nutrition experts. The RD and RDN credentials have identical meanings and legal trademark definitions.
1

Baugher AR, Beer L, Bradley HM, Evans ME, Luo Q, Shouse RL. Behavioral and clinical characteristics of
American Indian/Alaska Native Adults in HIV Care – Medical Monitoring Project, United States, 2011-2015.
MMWR Morb Mortal Wkly Rep. 2016;67:1405-1409. DOI: http://dx.doi.org/10.15585/mmwr.mm675152a1.
2

3

Ibid.

compared to the overall U.S. population living with HIV.4 IHS-operated, Tribal, and Urban
Indian Health Programs may receive Ryan White Program funds to provide HIV-related services
to the AI/AN population.5
In the survey question regarding cultural competency training, rather than merely offering a fillin-the blank option, it may be advantageous to request more details specifically related to the
National Standards for Culturally and Linguistically Appropriate Services in Health and Health
Care in order to obtain more quantifiable data,6 specifically people with disabilities, low health
literacy, racial and ethnic minorities, sexual and gender minorities, and limited English
proficiency.7
II.

Section II: Clinical and Supportive Services

In the survey question seeking to define availability of nutrition counseling, we suggest
confirming the type of provider supplying nutrition counseling. Nutrition counseling and medical
nutrition therapy provided by RDNs play an important role in maintaining the health status of
people living with HIV. Studies show both the health benefits of access to MNT and
nutrition counseling for people with HIV infections8 and the resulting decreases in their
healthcare costs.
In addition to inquiring about food bank or meal delivery services, it may be worthwhile to
inquire about assistance with applying for Supplemental Nutrition Assistance Program (SNAP)
benefits, given that HIV prevalence disproportionately affects low-income populations in the
U.S.9 and the documented associations between food insecurity and HIV viral suppression. 10

Centers for Disease Control and Prevention. HIV and American Indians and Alaska Natives.
https://www.cdc.gov/hiv/group/racialethnic/aian/index.html. Update May 18, 2020. Accessed June 30,
2020.
4

Indian Health Service. Ryan White Program and IHS. https://www.ihs.gov/hivaids/ryanwhiteprogram/.
Accessed June 30, 2020.
5

U.S. Department of Health and Human Services Office of Minority Health. The National CLAS Standards:
https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=2&lvlid=53#:~:text=The%20National%20Standards
%20for%20Culturally,the%20nation's%20increasingly%20diverse%20communities. Updated October 2,
2018. Accessed June 30, 2020.
6

National Committee for Quality Assurance. Building an Organizational Response to Health Disparities: A
Practical Guide to Implementing the National CLAS Standards: For Racial, Ethnic and Linguistic Minorities,
People with Disabilities and Sexual and Gender Minorities. Washington, DC: National Committee for Quality
Assurance; 2016. https://www.cms.gov/About-CMS/Agency-Information/OMH/Downloads/CLAS-Toolkit12-7-16.pdf. Accessed June 30, 2020.
7

Academy of Nutrition and Dietetics. HIV/AIDS Nutrition Evidence Analysis Project.
http://www.adaevidencelibrary.com/conclusion.cfm?conclusion_statement_id=250707. Accessed August 2,
2020.
8

9Aibibula W, Cox J, Hamelin A et al. Association between food insecurity and HIV viral suppression: a

systematic review and meta-analysis. AIDS Behav. 2017;21:754–765. https://doi.org/10.1007/s10461-0161605-5
Pellowski JA, Kalichman SC, Matthews KA, Adler N. A pandemic of the poor: social disadvantage and the U.S.
HIV epidemic. Am Psychol. 2013;68(4):197-209.
10

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III.

Section III: Enrollment and Initiation of Antiretroviral Therapy

In addition to assessing availability of various clinical and supportive services, including
nutrition counseling and food bank or meal delivery services, we also suggest that Section III
verify
 the approximate proportion of patients utilizing such services, and the frequency of such
usage, as eligibility requirements may determine, and
 whether staffing of each type of health care provider is adequate to meet demand.
Assessing capacity to implement the strategies of the Initiative can best be accomplished
by determining facility capacity to meet the current demand for each clinical and
supportive service. While Section III does ask about overall provider capacity, being as
specific as practical will likely enhance utility of the survey to assess capacity to meet the
Initiative’s strategies.
The Academy appreciates your consideration of our comment for the Medical Monitoring
Project Facility Survey docket. Please contact either Jeanne Blankenship at 312-899-1730 or by
email at jblankenship@eatright.org or Mark Rifkin at 202-775-8277 ext. 6011 or by email at
mrifkin@eatright.org with any questions or requests for additional information.
Sincerely,

Jeanne Blankenship, MS, RDN
Vice President
Policy Initiatives and Advocacy
Academy of Nutrition and Dietetics

Mark E. Rifkin, MS, RDN
Manager
Consumer Protection and Regulation
Academy of Nutrition and Dietetics

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