Planning Council Meeting Minutes June 27, 2019

HIV HEALTH AND HUMAN SERVICES
God’s Love We Deliver
Cicatelli Associates, 505 Eighth Avenue, New York, NY
Thursday, June 27, 2019 3:05-5:00 PM
MINUTES

Members Present: J. C. Park (Governmental Co-chair), M. Lesieur (Community Co-chair), S. Hemraj (Finance Officer), A. Abdul-Haqq, F. Barrett, L. Best, A. Betancourt, P. Carr, A. Casey (for G. Harriman), E. Casey, R. Chestnut, B. Cockrell, M. Diaz, M. Domingo, B. Fields, T. Frasca, MPH, C. Graham, B. Gross, J. Hudis, C. Kunzel, Ph.D., O. Lopez, A. Lugg, M. Mackey, J. Maldonado, L. F. Molano, M.D., J. Natt, D. Powell (by phone), C. Reyes, J. Schoepp, C. Simon (by phone), M. Singh, A. Straus, M. Thompson
Members Absent: M. Bacon, K. Balovlenkov, M. Baney, D. Beiling, R. Bruce, J. Dudley, J. Edwards, B. Fenton, MD, J. LiGreci, M. Mañacop, S. Reyes, A. Roque, D. Walters, B. Zingman, MD
Staff Present: DOHMH: D. Klotz, M. Lawrence, J. Colón-Berdecía, A. Guzman, C. Rodriguez-Hart, K. Mack, T. Gardet, K. Miller; Public Health Solutions: G. Kaloo, B. Carroll (by phone); J. Corbisiero (Parliamentarian)

Mr. Park and Mr. Lesieur opened the meeting followed by introductions. Ms. Chestnut led a moment of silence in memory of Dr. Charles Banderhorst, a compassionate HIV doctor who drowned recently while swimming in the Hudson River. The minutes of the May 30, 2019 meeting were approved with no corrections.

Ms. A. Casey reported that HRSA hosted a webinar on several policy changes, including: Ryan White Part A (RWPA) Client Eligibility Determinations and Recertification Requirements; Eligible Individuals and Allowable Uses of Funds; Use of RWPA Funds for Health Care Coverage Premium and Cost Sharing Assistance; and RWPA Funds for Core Medical Services and Support Services for People Living with HIV who are Incarcerated and Justice Involved.

RWPA providers will be receiving a memo on the impending changes that will be made to eSHARE’s intake and reassessment of non-testing RWPA programs. The changes that will be made will move towards standardizing and simplifying intake as much as possible across the service categories. A list of changes that will take place in the August 2019 deployment for the RWPA Intake Assessment and Reassessment was distributed. A summary of the changes was described, including adding questions about food insecurity, heptatis C, other medical conditions and quality of life. Questions removed included sexual behavior and partner-gender questions. Questions about oral health and disabilities still need to be finalized based on the Needs Assessment Committee’s recommendations.

On Monday, June 24, Care Coordination programs came together for the first meeting of all Care Coordination programs since the new program model launched. Staff from 25 programs met to reflect on lessons learned from Phase I of program implementation and hear from each other about serving TGNB clients in the program, using video conferencing, and assessing clients’ self-management skills. They also participated in a discussion about models for value-based payment.

HIV Planning Council Meeting Minutes – June 27, 2019 Minutes prepared by David Klotz 2 On June 5, the Long Term Survivors Wellness Coalition, in partnership with BHIV, hosted their 2nd annual Long Term Survivors Day Event at Baruch College. The event included a full day of educational and interactive activities, including long-term survivors’ panel discussion, awards presentations, movie screenings, cooking demonstrations, art exhibit, yoga and meditation, raffles, networking, music, and more.

On Monday, June 17, 2019, and Tuesday, June 18, 2019, Graham Harriman, as Chair of the Communities Advocating Emergency AIDS Relief (CAEAR) Coalition, attended the CAEAR Coalition Membership Meeting in Washington, DC. At the meeting, attendees planned CAEAR Coalition work for the year; shared information on their jurisdictions’ Ryan White programs, including successes and challenges; discussed Planning Council and community engagement; and discussed the Ending the HIV Epidemic: A Plan for America initiative.

The Health Department launched “Made Equal,” a new sexual health marketing campaign promoting the evidencebased finding that HIV cannot be passed through sex if the virus is undetectable. HIV treatment is safe and more effective than ever, and can reduce the amount of virus in the body to an undetectable level. People who maintain an undetectable viral load for at least six months and who continue HIV treatment cannot transmit HIV through sex. This is known as Undetectable Equals Untransmittable, or U=U. The campaign encourages New Yorkers to start and continue treatment if they have HIV and emphasizes that treatment is available regardless of their insurance or immigration status. “Made Equal” is designed to reduce HIV-related stigma, celebrate healthy sexuality and sexual pleasure, and redefine what it means to live with HIV. “Made Equal” is currently appearing in subway cars, subway stations, buses, and bus shelters across the city, as well as on digital media. More information about U=U is available on the DOHMH website.

Mr. Park added that, in order to enhance coordination between prevention and care, there should be updates at Council meetings from the HIV (Prevention) Planning Group and from the Council at the HPG meetings.

Ms. Hudis explained that HRSA will likely again cap the amount that an EMA can request in its grant application to a maximum of 5% over its current Base award. Since the cap was instituted, the Council has asked for the maximum in Base funding. The application spending request is theoretical, but must be justifiable based on data in the grant application narrative. PSRA will have the fall and winter to do scenario planning for an actual increase or decrease to the award. For the application, the EMA is required to submit separate Base and MAI plans. When we do the final plan for the actual award next year, it is one unified plan. The MAI funding request, which is completely formula-driven, always remains stable at the current year’s funding (for FY 2020 that is $8,616,680).

The Tri-County Steering Committee approved an application spending request that also asks for the maximum 5% increase (all TC programs are Base funded). As the majority of the service portfolio in Tri-County is newly re-bid, there is no data on spending that can be used to make adjustments in the service category allocations. Thus, the 5% increase is allocated across the portfolio proportionately based on the ranking scores for a total request of $4,722,487.

The NYC portion of the requested increase in the Base award is distributed in targeted increases to four categories, based on PSRA’s analysis of trends in over-spending and utilization as follows: Food & Nutrition ($1,450,000); Housing ($1,480,833); Supportive Counseling ($450,0000; and Legal ($247,000).

Ms. Hudis, on behalf of the PSRA, moved that the EC accept the FY 2020 Base NYC, MAI and Tri-County application spending plans as presented. The motion was adopted 30Y-0N.

FY 2018 Carry-over Plan Ms. Hudis explained that the carry-over plan is for the use of unspent funds from the previous year (FY 2018) in the current fiscal year (FY 2019, which ends on Feb. 29, 2020). Any carry-over funds not expended in this year must HIV Planning Council Meeting Minutes – June 27, 2019 Minutes prepared by David Klotz 3 be returned to HRSA. Typically, HRSA approves the carry-over plan in the fall, which leaves relatively little time for it to be spent. In previous years, due to the constraints on spending carry-over, the plan has called for the funds to be allocated to ADAP. The amount in the draft plan – $276,373 (a record low amount, all in Base Formula funds) – is preliminary and may be slightly adjusted once close-out is complete.

The Tri-County Housing programs received a $300,000 enhancement in their allocations in the middle of the previous grant year and have over-enrolled clients due to very active recruitment efforts. The programs can use $200,000 of the carry-over to maintain services to these clients. The carry-over funds will ensure that the enrollees continue to receive Housing services through the end of the grant year as the DOHMH HIV Bureau’s Housing Unit works with the programs to assess their ongoing needs and identify areas for client attrition. If there is a need for on-going additional funding in FY 2020, the PSRA can address that during the scenario planning process through any possible increase to the grant award, or through reallocating funds. The balance of the carry-over will go to ADAP.

Ms. Hudis, on behalf of the PSRA, moved that the EC accept the FY 2018-19 carry-over plan as presented. The motion was adopted 30Y-0N.

Mr. Klotz thanked Mr. Baney and Ms. Hudis for their superb leadership of the PSRA. Ms. Hudis said it was an honor to chair the meeting and thanked the members and staff for their outstanding contributions. She particularly thanked Saul Reyes for pushing to ensure that the planning process was more rigorous and understandable.

Mr. Carr and Ms. Lawrence presented the Needs Assessment Committee’s recommendations for filling the unmet needs for oral health services in the NYC portion of the EMA (Tri-County already has Part A dental services). NAC formed an Oral Health Sub-committee, which heard from consumers, received presentations from providers (including ADAP, Part F and the TC Part A providers) and CHAIN. The Committee found that Medicaid only covers essential services and does not adequately cover the oral health needs of PLWH. It provides low reimbursements, frequently does not cover replacements for lost or broken dentures, uses the cheapest quality material and does not support dental work that preserves the long term oral health of patients.

Dental case management has been shown to reduce anxiety, improve engagement through education and patient preparation for receipt of services. Dry mouth due to medication is no longer a major issue for PLWH – although it does continue to impact some patients, but issues of candida and thrush due to the use of inhalers is prevalent. Comorbidities are a major concern – some surgeries cannot be done when a patient has untreated dental problems. Consideration of oral health is not currently included in RWPA intake/ reassessment or screening – and only nominally addressed in Food and Nutrition programs. Stigma, compounded by fear and anxiety, continues to be a major issue impacting access to oral health services. Part F, once a safety net, is now described as non-functional and community based providers such as Callen-Lorde and Mount Sinai are fully booked.

The NAC’s recommendations are:

Fund Part A Oral Health Services in NYC. Where coverage is available, e.g., Medicaid and ADAP, needed services are not included or easily available, (e.g., gum and bone grafts, crown and bridgework, partials/implants when one tooth is missing, replacements for lost/broken dentures). Develop a screening tool with validated questions to identify oral health discomfort and issues among consumers, ensure linkage to oral health services, and develop health education modules that incorporate the need for dental services and oral hygiene. Dental case management within dental programs can afford the opportunity to address social isolation, reduce anxiety and improve consumer engagement and education. Linkage Agreements to Specialized, Complex and Emergency Services, including Provide coverage for implants and other highly specialized services i.e. crowns, orthodontia, and gum & bone grafting on a case-by-case basis. Support the Use of Quality Dental Materials, including Allow the use of food vouchers for electric toothbrushes (such as Quip) and other oral hygiene products. Recommend comprehensive, preventative and recurring dental services and procedures. Ensure coverage of at least 4 dental cleanings per year. Develop provider recommendations for common co-morbidities, i.e. Diabetes, Hepatitis C, HPV. Require trainings that address stigma among dental providers. Complement Medicaid and ADAP services to HIV Planning Council Meeting Minutes – June 27, 2019 Minutes prepared by David Klotz 4 ensure a robust system of care. Provider & consumer guidance on how viral load impacts oral care. Support data sharing and case conferences to comprehensively treat patients.

The next step in the process, after final Council approval, will be for the Integration of Care Committee (IOC) to create a service directive that meets Ryan White guidelines, after which PSRA will determine a ranking and allocation. The timing means that the new service will go into the FY 2021 application for services to begin in early 2021.

A summary of the ensuing discussion follows:

• However the service model is developed and financed, it must follow payer of last resort rules.
• IOC can recommend a mix a service providers (e.g., hospitals, clinics, community-based providers).
• The Council as a whole needs a better understanding of the link between oral health and overall health.
• Dental case management seems duplicative of some existing case management services. The service directive can address coordination of care and avoiding duplication.
• There is $2.5M in Part F funding at 13 agencies for dental services in NYC, plus 6 public clinics in public hospitals (H+H). There are opportunities to coordinate services, rather than put Part A resources into direct care.
• Half of Part F funding is for research, and existing dental programs have long waiting times for appointments. Also, not all services are reimbursable (e.g., Medicaid will only replace a broken denture after 7 years).
• When PSRA determines an allocation for the service, it will take into consideration costs and other payers. A likely scenario is a pilot program that will help determine the true extent of the need for Part A dental services.

Ms. Lugg, on behalf of the NAC, made a motion to accept the Oral Health recommendations as presented. The motion was approved 29Y=0N.

Mr. Carr and Dr. Kunzel were thanked for leading this initiative.

Mr. Guzman gave an update on national, state and local HIV policy issues. In September 2016, Legal Aid Society filed a civil rights class action against the City of New York and certain NYPD officers on behalf of women of color, many of whom are transgender, who have been wrongly arrested under laws prohibiting “Loitering for the purpose of engaging in a prostitution offense”) on the ground that the statue is unconstitutional on its face and unlawfully enforced by officers who target women for arrest based on race, ethnicity, gender, gender identity, and/or appearance. In June 2019, the parties announced a settlement, under which the NYPD agreed to amend its Patrol Guide to prohibit officers from relying only on gender, gender identity, clothing, and location to enforce the loitering statute. Officers must now provide more detailed narratives justifying detainment, and the NYPD Legal Bureau will monitor arrests under the statute.

In May 2019, activists and several New York City Council Members launched LGBTQ in 2021, a grassroots initiative to mentor and promote LGBTQ candidates during the next City Council term. LGBTQ in 2021 is dedicated to ensuring that our diverse community is represented in New York City government by electing lesbian, gay, bisexual, transgender, queer and gender non-conforming people to the City Council.

The following legislation was enacted by NY State recently: 1) the reproductive health act revises existing provisions of the law related to abortion; 2) prohibit discrimination on the basis of gender identity or expression, and include offenses regarding gender identity or expression in the list of those subject to treatment as hate crimes; 3) prohibit mental health professionals from engaging in sexual orientation change efforts with a minor patient and expand the definition of professional misconduct accordingly; 4) prohibit the use of the “gay panic” defense for certain homicide offenses where a defendant’s actions “resulted substantially from the discovery, knowledge or HIV Planning Council Meeting Minutes – June 27, 2019 Minutes prepared by David Klotz 5 disclosure of the victim’s sexual orientation, sex, gender, gender identity, gender expression or sex assigned at birth”.

In addition, legislation was passed by the Assembly or Senate but not enacted yet: 1) require the State to provide inmates, upon discharge from correctional facilities, with HIV prevention information, instructions on obtaining free HIV testing, and referrals to community-based HIV prevention, education, and counseling resources; 2) require treating hospitals to offer and make available to sexual assault victims a full regimen of PEP instead of a seven-day starter pack. Other proposed State legislation in progress includes: 1) repeal the loitering for the purpose of engaging in a prostitution offense; 2) vacate prior convictions for offenses resulting from sex trafficking, labor trafficking, and compelling prostitution; 3) decriminalize sex work, including prostitution and prostitution-related offenses, and would vacate prior convictions for offenses resulting from sex trafficking, labor trafficking, and compelling prostitution.

On May 21, 2019, the U.S. Department of Health and Human Services (HHS) published “Protecting Statutory Conscience Rights in Health Care,” a notice of its final rule. The same day, City Hall announced the city had joined a coalition of 23 other cities and states in a lawsuit seeking declaratory and injunctive relief with regard to the rule. On June 11, 2019, the National Family Planning and Reproductive Health Association (NFPRHA), Public Health Solutions, American Civil Liberties Union, and New York Civil Liberties Union announced they had filed suit challenging the rule. The complaint for declarative and injunctive relief argued that HHS lacks legal authority to promulgate the rule, and that the rule’s provisions radically expand underlying statutes contrary to the statutes’ text and purpose and in conflict with numerous other federal statutes and the First and Fifth Amendments. NFPRHA also issued a memo intended to assist NFPRHA members and other interested parties to better understand the key statutory authorities and regulatory effects of the rule on Title X-funded entities.

In March 2019, the U.S. Department of Health and Human Services (HHS) published, “Compliance with Statutory Program Integrity Requirements,” a notice of its final rule prohibiting any entity receiving Title X funding from providing or referring for abortions, even if those services or referrals are paid for by another source. Several states sued, securing a nationwide injunction. On June 20, 2019, the Ninth Circuit Court of Appeals lifted the injunction, allowing for the rule to take effect in every state but Maryland (due to a statewide injunction not affected by the ruling). This rule is largely seen as part of a larger effort to defund and close down Planned Parenthood, which also provides an array of LGBTQ health services across the country.

On May 21, 2019, the U.S. Department of Housing and Urban Development published, “Revised Requirements Under Community Planning and Development Housing Programs,” a notice of its proposed rule that would permit federally funded shelters to consider a range of factors in making a determination regarding an individual’s sex for the purpose of admission to any facility.

In two separate actions over the last few months, Express Scripts excluded seven HIV drugs for people starting treatment. In a letter to Cigna, the AIDS Institute claims the excluded medications are “in the HHS Guidelines recommended as the initial regimen in certain conditions, while several of the ‘preferred alternatives’ are no longer recommended for the treatment of HIV. One of these ‘preferred alternative’ drugs was even removed from the market in 2018.” The drugs were supposedly removed by Cigna because they are not as effective as newer drugs and have more side effects.

On June 20, 2019, Sen. Kamala Harris introduced the PrEP Access and Coverage Act, federal legislation that would: 1) Require all public and private health insurance plans to cover the drug—as well as all required tests and follow-up visits—without a copay, just as the Affordable Care Act requires insurance to cover contraception and other preventive services; 2) Fund a grant program to assist states, territories, and tribal communities in facilitating access to PrEP for people who lack insurance and reducing disparities in access to PrEP. The bill authorizes grants to cover the cost of the drug, as well as all associated tests and follow-up visits. The grants will also support outreach to physicians and other providers designed to increase understanding of PrEP and the recommended clinical practices for providing care. The Act would also prohibit companies selling life insurance, disability insurance, and long-term care insurance from denying coverage to customers who take PrEP or charging them higher premiums; and fund a public education campaign to reduce disparities in access to and use of PrEP by HIV Planning Council Meeting Minutes – June 27, 2019 Minutes prepared by David Klotz 6 educating the public—particularly high-need communities in which PrEP is underutilized—about the safety and efficacy of the drug and to combat stigma associated with using PrEP. It was noted that PrEP is listed as a top level preventative under the Affordable Care Act and thus is already part of the essential health benefits, but that this proposal would enshrine that into law, as well as offer additional protections.

There being no further business the meeting was adjourned.

Minutes approved by the HIV Planning Council on July 25, 2019