Members Present: Marcy Thompson (Chair), Fay Barrett, Billy Fields, Julio Gomez, Erin Harned, Graham Harriman, Jennifer Irwin, Emma Kaywin, David Martin, Freddy Molano, MD, John Schoepp, Claire Simon, Robert Steptoe, Steven Wilcox
DOHMH, PHS, NYS, CHAIN and Other Staff: David Klotz, Cristina Rodriguez-Hart, Scott Spiegler, Nadine Alexander, Ilana Newman, Kimbirly Mack, Mary Irvine, Roland Torres, Renee James, Connor Reynolds, Maiko Yamagido
Welcome/Roll Call/Moment of Silence/Minutes:
Mr. Harriman opened the meeting, followed by a roll call and a moment of silence. The minutes of the May 12th meeting were approved with no changes.
Needs Assessment Workgroups Summary
The four workgroups presented the results of their work.
Dr. Rodriguez-Hart reviewed the data sources used by the workgroup: NYC and NYS HIV surveillance reports, and the epi profiles prepared for the ETE and EHE plans. The workgroup did a deeper dive into specific topics (unmet need, estimate of PWH unaware of their status) and obtained Tri-County data. The workgroup also reviewed data on mental health status among RWPA clients, late diagnoses, and viral suppression by race/ethnicity for three priority populations (young MSM, cisgender women, older PWH).
Key takeaways from the data are: 1) Despite progress on new diagnoses, inequities persist over time; 2) Linkage to care decreased in 2017-2019 and timely viral suppression decreased in 2020; 3) Groups with highest levels of being unaware of their status are young people 13-24, MSM, heterosexual men, and certain racial/ethnic groups; 4) Over half of clients had at least one mental health diagnosis and these individuals were less likely to be virally suppressed despite high levels of engagement and retention in care; 5) Late HIV diagnoses had the largest racial/ethnic disparity among cisgender women, young MSM, and older PWH, but disparities existed for all metrics; and 6) Similar demographic groups impacted by new diagnoses in NYC and TC, but poverty was more prevalent in NYC. Viral suppression lower in NYC than TC.
Highlights of information gaps are: 1) Understanding the ways and degree to which COVID-19 influenced data; 2) People who do not have evidence of an HIV visit may or may not have need; unclear if need as defined by a visit with labs ordered is a good measure; 3) What are provider-client experiences like for marginalized populations and why do providers not offer HIV testing consistently to everyone; 4) “Unaware of HIV status” missing for TC and for many priority populations; 5) How has pandemic changed mental health needs; what are mental health outcomes for TC PWH; what accounts for their very low viral suppression; 6) What role do poverty, mental health, social isolation play in transmission; 7) More granularity needed on geographic differences and better measures of neighborhood and network factors that influence health; and 8) Unclear if HIV testing outreach to marginalized populations in TC and NYC are similar.
Highlights of the recommendations from the workgroup are: 1) Provide more recent data assessing impacts of pandemic and current status, e.g., investigate whether those lost to care during the pandemic were reengaged; 2) Develop more meaningful measures of unmet need (for HIV care); 3) Investigate HIV outcomes among priority populations not included in surveillance; 4) Provide HIV testing and other outreach to smaller, more ignored populations; 5) Provide more intensive and client-centered services to PWH with mental health disorders; fund experienced therapists that have time set aside for PWH clients; 6) Investigate current landscape of mental health needs given pandemic’ 7) Screen Black and Latina women early in HIV disease progression; 8) Investigate improvements to provider reporting forms to reflect current needs; 9) Better address stigma, neighborhood-level factors, and other determinants of equity; 10) Provide equitable funding and services across geographic areas.
Questions and comments following the presentation included:
- HIV testing and lab work, as well as screening for syphilis, requires a visit to a site for blood draws, even in an era of telehealth and social distancing.
- Care for the homeless is inadequate and even more challenging at a time of sweeps of homeless from public spaces.
- Care for the undocumented faces barriers around people not knowing the system.
- Home tests are useful, but connection to care drops off considerably for people who test at home.
Mr. Spiegler reported that the workgroup started with a literature review that found that stigma reduction and issues around health equity and anti-racism were prevalent. The workgroup pursued the possibility of doing a survey of RWPA providers. It turned out that the AETC was developing a survey on stigma and provider capacity for the entire HIV workforce in NY. The workgroup reviewed the draft survey, providing feedback, particularly on anti-stigma and health equity needs. The survey will be launched next week and DOHMH will help distribute it throughout the provider network. Results will be presented in the fall along with next steps. They are also looking at bringing subject matter experts (e.g., from the ESCALATE project) to look at gaps that need to be addressed (e.g., training).
Mr. Harriman, Mr. Schoepp and Ms. Irwin explained that the CDC and HRSA defines a resource inventory as a listing and description of the providers of HIV-related services, types of services they provide, where, and to whom (both RW and non-RW providers). The workgroup used the following documents: Public Health Solutions Portfolio Summary; Payor of Last Resort Analysis; EHE Situational Analysis, RWPA 2022 Grant Application Coordination of Services and Funding Table; and Geographic Distribution of RWPA Funding. The workgroup identified a need for updated HIV prevention contract information and recommends the use of the status neutral continuum. There is a need to review RW Part B contracts to better understand geographic coverage. Also, maps include both administrative and service sites, making it difficult to interpret the amount of coverage at a site. Given the limitations, the key takeaways from the analysis are: 1) Poor coverage in the Far Rockaways and in Southern Brooklyn (generally across the three maps); 2) Need for more Mental Health services in southern Brooklyn Queens, and Staten Island; 3) Food and Nutrition needs more in Brooklyn and better coverage in Queens; 4) Health Education and Risk Reduction needs more overage in Queens and the Bronx—this may be an opportunity to increase offering of groups in these boroughs; 5) Limited geographic coverage for legal services in Queens. No legal coverage in the Bronx; 6) Limited Early Intervention Services coverage in Brooklyn; 7) Poor housing coverage in the Bronx and Queens; 8) Medical Case Management needs more Bronx and Queens sites, too much coverage in Manhattan. The workgroup recommends that RFPs include language for adequate geographic coverage upon award to better serve Bronx and Queens, and parts of Brooklyn, specifically.
Recommendations related to payor of last resort are: 1) Better coordinate funding streams, especially with Ryan White and other funding streams; 2) Coordinate across Medicaid services (mental health, for instance) and RWPA, given separate intakes, data collection and funding; 3) Difficult to maintain a client centered practice when funding streams have different requirements; 4) HIV testing programs should clarify funder for each service, given the multitude of payers; 5) More self-testing would be helpful since self-swabbing/home tests/self-administered testing is more common.
Information gaps from the Situational Analysis include: 1) statement about PWH who aren’t able to go back to work; 2) information on the use of telehealth; 3) statement on the training of providers who will be managing the care of >50 population; and 4) Need to partner with Geriatric departments for care of PWH over 50. Recommendations include: 1) Better to encourage consumer employment in a variety of roles; 2) Improved coordination to address mental health; 3) need systems to address the needs of PWH who are caretakers of parents, partners, family members; 4) address gaps in access to technology; 5) Address provider bias through training and real-world experience; 6) Expansion of HIV and HCV testing; and 7) Design systems to implement Immediate provision of Antiretrovirals (IART).
From the Grant Application and geographic distribution data, recommendations are: 1) Increase funding for housing; 2) Increase funding for Women Infants, Children, and Youth services; 3) More mental health investment in the Bronx; 4) More psychosocial support in the Bronx and Queens; and 5) More CBO/Hospital partnerships.
Questions and comments following the presentation included:
- The group did not look at provision by ZIP code, but overlaid geo maps onto borough-based surveys.
- An inventory of technology available to clients for telehealth would be helpful, if possibly not feasible.
- Maps do not identify providers by type (e.g., hospital, CBO).
Service Needs and Gaps
Ms. Harned reviewed the workgroup’s aims, especially to identify the service needs and gaps in service receipt of PWH in the New York EMA based on RWPA service categories and CHAIN data. There was a brief overview of what CHAIN measures from the 1319 interviews conducted with 874 individuals between 2015-20. Key findings, information gaps and recommendations were given for the following areas:
Behavioral Health: need for Spanish-language and trans-affirming mental health care, care outside standard M-F/9-5 hours. Case Management: more medical and non-medical case management; continue to provide services (including short assessments) to clients who have graduated out of more intensive services. Childcare: increase access to reimbursable services. Clothing & Household Items: use emergency financial assistance for household items and increase information about this opportunity for providers and clients. Employment: Increase information about existing community employment services for both providers and clients; increase availability of benefits counselling to support clients seeking employment or changes in employment. Financial Assistance: Reduce administrative hurdles; Fund peers for financial assistance; review requirement to first phone or connect online with a provider; provide alternative means for clients with limited technology or connection services to connect with service providers; tailor information about available services to reach younger PWH, especially for LGBT youth & youth of color.
Food: Increase funding for case managers & benefits navigators; increase availability of information about support system opportunities; increase coordination among existing food service providers; increase availability of resources for provider staff; increase availability of information about locally available services; increase availability of information about medically-tailored food assistance; and increase linkages between medical and social service providers to connect clients with medically-tailored food assistance. Health Care: Increase availability of/information about self-directed care opportunities, especially among case managers & other provider staff.
Housing: Increase availability of/information about eviction prevention services; reduce administrative access hurdles & increase funding for provider staff to support navigating financial services. Legal Services: Increase availability of/ information about eviction prevention and other legal services available for undocumented PWH; increase availability of/ information about existing legal services. Oral Health: Create a registry of trauma-informed dental care providers; ensure any available information is shared with agency staff who can assist clients with limited internet access and ensure information in resource directory is available to those with limited internet access and in multiple languages; and increase funding for dental insurance and encourage dental providers to accept more insurances.
Translation: Increase availability of non-language translation services like assistance for those with low health literacy, braille, & services for anyone with special needs. Transportation: Expand funding for MetroCard use and distribute unlimited passes; increase funding for paratransit and car sharing rides (especially in TC); give clients ride share gift cards or use of a pre-loaded car ride app; and increase funding for provider staff (e.g., case managers & benefits navigators) to connect clients to transportation services.
In summary, very high need service areas include: Primary Care, Oral Health, Non-Medical Case Management, Housing, Financial and Food. Mental health and transportation are high need areas. Moderate need areas are Employment Services and Medical Case Management. There are very high or high gaps in service in Oral Health, Transportation and Employment Services. Cross-cutting recommendations include: 1) Increase funding for provider staff to increase number of case managers/ benefits navigators available to assist clients in accessing services; 2) Require (or increase funding for) cultural competency trainings for all provider staff to be held annually; 3) Ensure intake forms and other paperwork are designed so that clients can record their information accurately; 4) Quickly communicate policy changes impacting services to providers & clients; 5) Create and distribute “ask me about” one-pagers to providers featuring services clients may be eligible for but may not know to ask about; and 6) Increase availability of information beyond just websites & ensure available information is accessible (e.g., in multiple languages, appropriate for those with vision difficulties).
Questions and comments following the presentation included:
- Financial assistance need defined as self-reporting need for funds for household expenses, housing, food, out-of-pocket medical expenses, etc.
- CHAIN reaches people out of care or who have dropped out of care (both medical and social services), but it’s a small part of sample. It can be difficult to reach the out of care.
- Women of trans experience need to be a bigger focus to determine service needs and gaps, as this population has particular challenges accessing services.
- Take a closer look at how employment practices rise barriers to certain populations.
Needs Assessment Next Steps
Mr. Harriman explained that DOHMH is in the process of securing a writer for synthesizing the workgroups reports, writing the draft Needs Assessment, and planning a public forum for broader community input. The deadline for submission may need to be extended from December into early 2023.
Mr. Harriman thanked Finn Schubert for his service as co-chair. Mx. Kaywin will become the co-chair with Ms. Thompson starting in the fall.
The Committee and staffed were thanked for their excellent work this cycle.
There being no further discussion, the meeting was adjourned.