Planning Council Meeting Minutes January 31, 2019

HIV HEALTH AND HUMAN SERVICES
LGBT Center, 208 W. 13th Street, New York, NY
Thursday, January 31, 2019 3:00-5:00 PM
MINUTES

Members Present: J. C. Park (Governmental Co-chair), A. Abdul-Haqq, K. Balovlenkov, F. Barrett, A. Betancourt (by phone), D. Beiling, L. Best, R. Bruce, P. Carr, E. Casey, R. Chestnut (by phone), B. Cockrell, M. Diaz, M. Domingo, J. Edwards (by phone), B. Fields, T. Frasca, MPH, C. Graham, B. Gross, G. Harriman, C. Kunzel, Ph.D. (by phone), M.

Mackey, M. Mañacop, L. F. Molano, M.D., J. Natt, D. Powell (by phone), S. Reyes, A. Roque (by phone), J. Schoepp, C. Simon (by phone), A. Straus (by phone), B. Zingman, MD 

Members Absent: M. Bacon, M. Baney, J. Dudley, B. Fenton, MD, S. Grant, S. Hemraj, J. Hudis, M. Lesieur, J. LiGreci, O. Lopez, A. Lugg, J. Maldonado, C. Reyes, R. Rios-Vergara, M. Singh, M. Thompson, D. Walters 

Staff Present: DOHMH: D. Klotz, D. Wong, M. Lawrence, J. Colón-Berdecía, A. Casey, S. Braunstein, PhD, S. Scott, F. MacKee, A. Guzman, J. Kirkland, K. Mack, L. Torian, C. Rodriguez-Hart, T. Gardet; Public Health Solutions: B. Carroll (by phone), G. Kaloo; WCDOH: J. Lehane, PhD; J. Corbisiero (Parliamentarian)

Mr. Park and Ms. Barrett opened the meeting, followed by introductions and a moment of silence in honor of Carol Channing, who was an ally for PLWH and LGBT people.  The minutes of the December 20, 2018 meeting were approved with no corrections. 

Dr. Braunstein presented on trends and highlights from the recently released 2017 NYC HIV Surveillance Report.  NYC DOHMH collects data that providers and laboratories are mandated by NY State to report including positive HIV diagnostic test results, viral load and CD4 results, and genotypes.  Much of the data come from medical chart review and laboratory report forms.  We also receive provider report forms, conduct patient interviews, and match to other registries like vital statistics to obtain death information.  This allows us to report on numbers of new HIV diagnoses, people living with HIV, deaths among people with HIV, and HIV care outcomes using labs.  Surveillance data is designed to be comprehensive for all people diagnosed and living with HIV – so that it can be used for population-level monitoring of HIV – but it also only contains a limited amount of information on those people.  There are data on gender, race and ethnicity, age, residence, and transmission risk, but in terms of more detailed information, such as mental health or incarceration history, data aren’t as complete so we don’t generally report on these topics.  There is a good overall picture of which subpopulations are most impacted by HIV and how things are changing over time.  Unfortunately, there aren’t data to explain why certain groups might be more affected or the specific reasons for a trend (DOHMH relies on research from other institutions and providers on the ground to provide those explanations).

Nearly all groups are experiencing declines in HIV rates, except TG and API (stable over this period with relatively low absolute numbers).  Also, the HIV diagnosis rate decreased in the last 5 years (2013-2017) from 34.4/100,000 to 25.3/100,000.  Groups experiencing high proportions of new diagnoses are: Men, Blacks, Latinos, people ages 20-39, Brooklyn residents, men who report sex with men.  HIV diagnosis rates show major disparities, which are persistent over time.  In 2017, 1 child born in NYC who was perinatally infected with HIV.  DOHMH tracks acute HIV infection (AHI), classifying AHIs according to a case definition for surveillance based on results of laboratory testing.  In 2017, 14% of new diagnoses were AHI.  MSM are overrepresented among AHI cases, in part due to higher testing frequency compared with other groups.  Trends over time in AHI show that, as testing has increased and more people are being diagnosed earlier in infection, including in the acute phase, the proportion of AHI has grown – from 1.9% in 2008 to 13.7% in 2017.  

In spite of the opioid epidemic, new HIV diagnoses among people who inject drugs continue to see a precipitous decline.  There were 64 total new diagnoses among IDU and MSM-IDU in 2017, down from 979 in 2001 (94% decrease).  There number of new HIV diagnoses among people 65+ is decreasing over last 5 years.  In 2017, 2.4% of new diagnoses were among people ages 65+.  In 2017 newly diagnosed persons ages 65+ were: 62% men and 38% women (no TG); 60% Black, 17% Latino/Hispanic, and 17% White; and 31% heterosexual contact, 19% MSM, 11% IDU, and 38% unknown risk. 

There is great progress towards the Ending the Epidemic (EtE) goals around new diagnosis and estimated new HIV infection with actual data through 2017, and projected data through 2020.  Projections here for new diagnoses and incident infections for 2018 to 2020 are based on estimated accelerations in declines over these years to get to our goals –  assuming that’s a reasonable scenario.  The specific projected declines could be different from the projections here, and we could still get to the targets; also, of course, the actual numbers/estimates we see moving forward may be different from these projections.   

DOHMH also tracks clinical outcomes for people living with HIV using HIV-related laboratory tests reported to surveillance.  A key outcome is viral suppression.  We show 5-year trend in viral load suppression (VLS) among people receiving HIV care in Figure 13.2 in the report. In 2017, 85% of PLWH in care were virally suppressed on most recent VL.  Women and transgender people, Blacks and Latinos, young people, people who inject drugs have lower VLS rates.

UNAIDS established global targets for HIV care for 2020: 90% of PLWH will know their HIV status; 90% of diagnosed will receive ART; 90% of those receiving ART will be virally suppressed.  In NYC in 2017, all racial/ethnic groups met the HIV status and viral suppression goals, but none met the receiving ART goal, with the percentages receiving ART ranging from 84% for Black PLWH to 89% for White PLWH.

Ms. Scott presented on transmitted drug resistance (TDR), which is when a person acquires a virus that is resistant to 1 or more antiretroviral drugs.  PLWh need to get on therapies that work for them to achieve VLS and reduce transmission.  Resistance testing happens when someone tests positive and a physician orders a genotype test, which is also reported to DOHMH.  The test sequences HIV’s genome, detects any mutations in the virus that might confer resistance, and identifies how susceptible that virus is to the drugs classes available (nucleoside analogues, protease inhibitors, etc.).  The proportion of people with new diagnoses who have TDR has remained relatively steady (16.2% in 2017), mostly to the class of nonnucleosides.  In 2017, >95% of newly diagnosed persons in NYC were sensitive to a first-line integrase inhibitor based regimen.

Mr. MacKee described the DOHMH BHIV social marketing and community engagement efforts launched in spring 2018, called “Listos”, to promote PrEP among Latino MSM.  Listos was the first sexual health campaign conceived entirely in Spanish from its inception.  Focus groups of Latino MSM from 7 countries were conducted to explore stigma, cost and other issues that might create barriers to PrEP use.  Four different campaigns were presented in collaboration with the Latino Commission on AIDS.  Ads have been placed in subway cars on all 9 lines and 23 different stations.  Some posters were vandalized in Queens and Brooklyn, showing the need for visibility.  The social media portion of the campaign delivered over 50K clicks to the website.  The campaign had more traction in the MSM segment.  Twitter and hook-up apps had better performance, especially among MSM.  There was also print and TV coverage of Listos.  The campaign was expanded in late 2018 and will address testing and treatment as prevention.  The next steps include a second round of placements and working with community advisory boards on expanded strategies. 

A summary of issues raised in discussion follows:

• 79.7% of all Part A clients are virally suppressed.  This is lower than the Citywide average, but it should be noted that many Part A programs (particularly Medical Case Management) target the unsuppressed.
• The uptick in AHI as a proportion of new diagnoses may be partially due to improvements in testing technology, with tests that can tell if an infection is recent. 
• Measures of sustained VLS are needed, especially in the era of U=U.
• DOHMH does not monitor immigration status, only country of origin by birth.
• Tri-County data is collected by the State DOH and will be presented to the Tri-County Steering Committee.
• Drug resistance can be passed on through sexual transmission of HIV.
• Given the expense of genotype testing and the fact that current regimens are effective, even if not all three drugs in the combination are fully active, means that clinicians are rethinking the need for routine genotyping. 

Mr. Klotz presented the draft FY 2019 spending plan.  The EMA received its notice of grant award for the Fiscal Year 2019, which will begin on March 1^st.  The EMA’s new award is $94,232,524 – a reduction of $1,566,536 (1.65%).  The reduction is in the portions of the award over which we have no control: Base Formula and Minority AIDS Initiative (MAI) funds, which are calculated by HRSA based on the number of reported HIV cases in the EMA compared to the other 51 EMAs.  This is a testament to our success in prevention, even though it hurts us in the amount of Ryan White money we receive.  The loss in formula funding was slightly offset by an increase in Supplemental funding, which shows that we made a good case in our grant application to HRSA.  Details of the breakdown in the award will be given in the Recipient (Grantee) Report.

Two weeks ago, the PSRA Committee approved a methodology for absorbing a cut to the award up to 3.5%.  The methodology was used to apply the actual amount when we received the notice of grant award in time for the Executive Committee, so this is a final spending plan.  The first $581,067 of the reduction is absorbed through the savings in the carrying cost of programs.  There are service categories (Non-medical Case Management, Mental Health, Health Education) that will not require the same funding level due to permanent contract take-downs or terminations and are listed in Column I of the spending plan.  Also, equal amounts in ADAP and Housing are shifted between Base and MAI in order to balance the portfolio, as we have to allocate the exact amounts that we received in our Base and MAI awards.  This has no impact on programs or overall service category allocations.

The rest of the cut to the award can be absorbed through a reduction of $837,815 in the ADAP allocation.  The State ADAP Director has assured us that they have sufficient funds from other sources to maintain service levels.  There is also a small adjustment to the Tri-County allocation of $6000 to correct an error in the current year’s approved spending plan, which was translated to less on the full Spending Plan because we used to calculate the administration portion of Tri-County separately.

A motion was made and seconded to accept the FY 2019 final spending plan as presented.  The motion was approved 24Y-0N.

Mr. Harriman presented explained the FY 2019 notification of grant award from HRSA.  The EMA lost 1.47% in Base funding (all in formula, which was slightly offset by a 0.3% increase in supplemental funding).  The MAI award was reduced by 3.23%.  The total reduction was 1.64% for a new award of $94,232,524.  HRSA gave the EMA’s FY 2019 grant application a score of 98 (out of 100) and noted only one minor weakness among its many strengths.  

Ms. A. Casey reviewed the FY 2018 2^nd quarter commitment and expenditure report (for 3/1/18-8/31/18), which is part of the Council’s legislative mandate to assess the efficiency of the administrative mechanism for the rapid disbursement of Part A funds.  Spending would be expected to be at about 50% mid-year.  Actual total expenditures were at 42.33%, which is in the ballpark of expectations, given that this year the EMA received its award from HRSA late and in two parts, and sub-contractors were cautious about spending early in the year due to the uncertainty on funding levels.  With the reprogramming plan approved by the Council, funds are expected to be fully expended by the end of the year.  Some areas highlighted included: higher than expected under-spending in Food & Nutrition and Supportive Counseling, which had to absorb increases in their allocations; and Transitional Support for Incarcerated, which had a delay in drawing down funds in the beginning of the year.  Those programs are expected to be fully expended by the 4^th quarter close-out. 

In response to a question, Ms. A. Casey explained that virtually all programs in the EMA are MAI-eligible (targeted to improve the health outcomes of racial and ethnic minority PLWH), and that individual contracts must be either Base or MAI, not split between the two.  

Mr. Guzman presented briefly on the following policy issues:

• Mayor de Blasio has announced plans to launch a comprehensive package of health services available on a sliding scale to anyone without insurance.
• Governor Cuomo has signed a number of pieces of progressive legislation, including codifying access to reproductive health services, and prohibiting discrimination on the basis of gender identity.
• Other proposed State legislation would prohibit insurance companies from denying coverage for PrEP and PEP; ensure comprehensive coverage for contraception; require HIV, HCV and STI prevention programs for employees and inmates in State correctional settings; decriminalize possession of syringes and permit safe injection sites. 
• The recent (and possible future) partial federal government shutdown may affect delivery of important benefits (e.g., SNAP).

There being no further business the meeting was adjourned. 

Minutes approved by the HIV Planning Council on December 20, 2018