Thursday, November 18, 2021
By Zoom Videoconference
M I N U T E S
Members Present: G. Harriman (Governmental Co-chair), D. Walters (Community Co-chair), P. Carr (Finance Officer), A. Abdul-Haqq, S. Altaf, R. Brown, G. Bruckno, M. Caponi, E. Casey, R. Chestnut, B. Cockrell, J. Dudley, J. Edwards, B. Fields, R. Fortunato, M. Gilborn, J. Gomez, C. Graham, B. Gross, R. Henderson, E. Kaywin, M. Lesieur, D. Martin, L. F. Molano, MD, C. Moore, J. Natt, H. Nguyen, J. Palmer, G. Plummer, D. Powell, M. Rifkin, F. Schubert, M. Thompson, V. Velazquez
Members Absent: F. Alvelo, M. Bacon, M. Baney, L. Beal, D. Beiling, A. Betancourt, R. Bruce, P. Canady, B. Fenton, MD, A. Lugg, L. Ruiz, C. Simon, T. Troia, R. Walker, S. Wilcox
Staff Present: DOHMH: S. Braunstein, PhD, D. Klotz, M. Lawrence, C. Rodriguez-Hart, J. Colón-Berdecía, S. Spiegler, J. Carmona, J. Lawrence, J. Williams, B. Meisel, S. Torho, K. Miller, M. Pathak; Public Health Solutions: A. Shahi, G. Ashby-Barclay, R. Santos
Agenda Item #1: Welcome/Introductions/Minutes/Public Comment
Ms. Walters and Mr. Harriman opened the meeting followed by a roll call and a moment of silence. The minutes from the November 18, 2021 meeting were approved with no changes.
Agenda Item #2: HIV Epidemiology Update: 2020 NYC HIV Surveillance Report
Mr. Harriman introduced Assistant Commissioner Dr. Sarah Braunstein, noting that she will present only NYC data, as DOHMH only collects data for the five boroughs. NYS DOH collects data for the rest of the State and will present Tri-County data to the Tri-County Steering Committee in March.
Dr. Braunstein presented the recently released 2020 NYC HIV Surveillance Report, noting that 2020 reporting was shaped by the COVID pandemic and the attendant delays and disengagement in care as people were encouraged not to seek non-essential in-person care. The number of HIV tests in 2020 dropped considerably starting in March with the onset of the COVID pandemic.
The number of new HIV diagnoses fell to a record low of 1396 (compared to 1763 in 2019 and 2237 in 2016). There were 917 AIDS diagnoses and 1933 deaths among PWH. HIV incidence has continued its downward trend among all gender, race and transmission categories. People of color still make up the majority of new diagnoses (Black people are 47% and Hispanic are 34%), much higher than their percentage of the overall NYC population. New diagnoses are also concentrated among those living below the poverty level. Twenty-four percent of new diagnoses were among people born outside the US, and of those, almost a third were from the Caribbean (excluding Puerto Rico & USVI), and more than a third from Latin America.
Acute HIV infection mostly in MSM and most of those Black and Hispanic. Among Blacks, people in their 20s are the largest group. Ten percent of all new diagnoses are in the acute phase (up from 7%), which means that more people are being identified at the onset of infection. There was only one possible case of maternal to child transmission (still under investigation). The rate of timely initiation of care (defined as viral load, CD4 or genotype test within 30 days of diagnosis) among newly diagnosed is at 80% (up from 74% in 2016, but flat from last year). Viral suppression among all PWH is at 83% (about the same as last year, but up from 80% in 2016). The care continuum (aka treatment cascade) was described, showing the percentage of PWH who are diagnosed, received care, prescribed ART and virally suppressed. NYC has reached the UN’s 90-90-90 goals for testing and viral suppression, and is just under for people on ART, but some populations lag.
The age-adjusted death rate for PWH shows that HIV-related deaths continues to decline overall, but the non-HIV related death rate ticked up in 2020 due to COVID. There are inequities in this statistic by race/ethnicity. This is reflected by the geography of death rates, with the highest rates in low income areas of the Bronx, central Brooklyn and parts of Queens.
A summary of the discussion follows:
- Linkage to care and health outcomes data can be broken out by sub-population, which will show disparities by race and income, among other factors.
- There is no population-level data on PrEP use.
- Results of home tests are not reported to the surveillance system until confirmatory lab tests are performed.
- The total number of confirmed PWH reported to DOHMH and not known to have died is ~84K, but DOHMH uses a formula to estimate the total number of PWH to account for those who have moved out of the area. The estimated total is about 129K.
- The number of women infected through sexual contact with women is very small. DOHMH tracks sex at birth and current gender identification as well as gender of partner for partner notification services.
- Data on gender and sexual orientation can be influenced by the data collection method.
- The data collected is what DOHMH uses to use to develop the care continuum, but COVID has made the picture more complex.
- Age-specific data on new and concurrent diagnoses is available through Epi Query.
Agenda Item #3: Revised Framing Directive
Mr. Harriman introduced the Framing Directive by noting that it is past time to address the persistent inequities in health outcomes and address issues of equity and social justice in Ryan White Part A (RWPA) services. After the first version of the Directive was voted down (mostly through abstentions), the Integration of Care Committee reviewed the Directive, reworking it to address the concerns that were raised.
Ms. Fortunato and Mr. Powell presented the revised Framing Directive, approved by the Integration of Care Committee (IOC) on December 3rd. Formerly known as the Master Directive, this document guides all services in the RWPA portfolio. The Directive utilizes an implementation science framework to clearly establish the context of the portfolio and align implementation strategies with that context. In this directive, the entire RWPA portfolio is considered as the intervention.
The first sections of the directive, Determinants, Intervention Characteristics, and Inner Setting, Outer Setting, Characteristics of Individuals Implementing the Intervention and Process establish the context in which the RWPA portfolio operates. The Implementation Strategies and Mechanisms are evidence-based responses to this context that seek to achieve optimal service delivery and health outcomes for PWH. The Outcomes (Implementation and Clinical/Patient) are the identified metrics to track the portfolio’s progress (or lack thereof) in improving health outcomes. Two relevant inner settings (Care and Treatment Program (CTP)/Department of Health & Mental Hygiene (DOHMH), and RWPA Funded Organizations) describe expertise, organizational structure and bureaucracy and the stigma and equity characteristics of both. Outer Setting Characteristics are drawn from the DOHMH EHE Situational Analysis (e.g., generally high but inequitable achievement of outcomes along the HIV care continuum).
The Directive describes implementation strategies to be initiated over time. To prevent redundancy, organizations may substitute other work, with CTP approval, for the following strategies: 1) pay equity & racial equity analysis; 2) organizational stigma assessment and plan that must be conducted by all contracted & monitoring bodies; 3) prepare consumers to be active participants in the implementation of client centered care; 4) facilitate the development of client crisis plans grounded in research; 5) train staff to deploy non-police alternatives, where police are called as a last resort; and 6) develop mechanisms to enhance or modify programs mid-contract to reflect emerging evaluation.
Quality Management-related strategies include: 1) recruit, identify, train, and prepare organizational champions to ensure participation in quality improvement processes; 2) collect new and updated client assistance resources to create a searchable live site/resource map that facilitates the completion of comprehensive and appropriate referrals and linkages; 3) provide technical assistance to enhance uptake of current and emerging technologies that reduce client and staff burden train staff to deploy non-police alternatives, where police are called as a last resort; and 4) support tools and activities (technical assistance on organizational development, grant writing, development of mutually beneficial collaborative funding opportunities) that support the development of a multi-organizational initiative that facilitates leveraging supplemental public/private funding sources to build economies of scale.
The Directive requires training and education of stakeholders (e.g., hard reduction, trauma-informed care, outreach protocols, health equity, anti-racism/anti-oppression, gender affirmation). Training calendars and resources should be coordinated throughout DOHMH, DOHMH will incentivize inclusion of disproportionately impacted populations of PWH, and DOHMH will support modifications to existing spaces, resources, and materials to ensure reasonable accommodations to persons with any type of disability. DOHMH will also modernize and streamline data collection to minimize data burden and improve identification of unmet needs, set up an anonymous suggestion box to field questions/comments from program staff, and funded sites will set up mechanisms for clients to provide each other with social support to reduce stigma and isolation.
The Recipient (CTP) will report on the outcome measures to the Planning Council to be reviewed by a workgroup, made up of the recipient, the Council and agency representatives who have the authority to examine and amend the outcomes, and determine the methods and a timeline of outcome data collection that is feasible to RWPA providers, the Council and the Recipient. Outcomes include: increase of PWH aware of their status, viral suppression, declines in reports of stigma and racism, etc.
Ms. Casey expressed her concern that the Directive does not truly address the problems that it names. She also expressed frustration that her concerns about feasibility (e.g., HR departments will not be able to provide salary breakdowns by race) were dismissed. An effective path to addressing stigma and inequities is needed and dialogue should not be shut down.
Mr. Harriman responded the IOC did address the issues raised by Ms. Casey and revisions were made to address some of them, as per the Committee’s deliberations. Mr. Lesieur stated that he shared many of Ms. Casey’s concerns, particularly around the complexity of the document. The revisions make it clearer, and while he still had reservations, he supports the Directive as long as there is a commitment to addressing issues that come up during implementation, and making further revisions if needed. Mr. Powell added that the Directive will not fix all the systemic issues in the RWPA program, but is part of an ongoing process to move the system forward and improve care. Ms. Fortunato added that the Directive was developed through an extensive community planning process that incorporated all the concerns that were raised, but in the end, Council products are approved by majority vote.
Ms. Plummer stated that the Recipient supports this Directive, as it aligns with the NYC Board of Health’s recent declaration of racism as a public health crisis. The Recipient is committed to implementing this in partnership with all stakeholders. She acknowledged that the process will be imperfect, but that they will use continuous quality improvement to share best practices, make adjustments to work out any snags, and ensure that work is not duplicative.
Mr. Powell, on behalf of IOC, made a motion to approve the Framing Directive as presented. The motion was adopted 31Y-0N.
The leadership, membership and staff of the IOC were thanked for their efforts to create this directive.
Agenda Item #4: Recipient Update
Ms. Plummer reported that on December 1st, the White House released the National HIV/AIDS Strategy for 2022-2025. The Strategy will accelerate the nation’s work to end the HIV epidemic in the U.S. by 2030. The NY EMA has submitted 13 abstracts to the 2022 National Ryan White Conference, which will take place August 23-26, 2022 with the theme “The Time Is Now: Harnessing the Power of Innovation, Health Equity, and Community to End the HIV Epidemic.” Topics of the abstract include the Council’s HIV & Aging Service Directive, SMI recommendations, Framing Directive. and the use of implementation science.
HRSA/HAB released updated guidance that eliminates the six-month client eligibility recertification requirement for RWHAP programs, instead allowing RWHAP recipients and subrecipients to conduct timely eligibility confirmation in accordance with their policies and procedures. The PCN also states affirmatively that immigration status is irrelevant for the purposes of eligibility for RWHAP services.
Almost 200 stakeholders, including service providers and consumers, attended the 8th annual RWPA Power of Quality Improvement Conference on December 14th with the theme “Building Resilience, Actualizing Equity, and Ending the Epidemic”. There was an opening plenary followed by breakout sessions, including one from the Consumers Committee on the HIV& Aging Service Directive. The NYC World AIDS Day event honored five organizations for building equity and resilience in the face of two pandemics: Argus Community, Caribbean Equality Project, Children’s Aid, Hudson Valley Community Services, and the Consulate General of Mexico.
On 01/12/2022, Public Health Solutions (PHS), on behalf of NYC DOHMH, will release The Ending the Epidemic in New York City: The Undetectables Viral Load Suppression Program and Crystal Methamphetamine Harm Reduction Services RFP. PHS will release the Oral Health Care Services in New York City concept paper on December 20th with the forthcoming RFP set to be released on 02/08/2022 for programs starting 09/01/2022.
Agenda Item #5: Planning Council Chairs Update
Mr. Harriman reported that the Joint Planning Council/HPG Policy Committee meets on January 25th and will review the National HIV/AIDS Strategy and EHE plan to help prioritize issues to focus on. He thanked all the stakeholders who contributed in a challenging environment to the many accomplishments in the EMA’s RWPA program. He also noted a new DOHMH advisory on staying safe from COVID-19 during the holidays as cases surge.
Mr. Fields and Ms. Graham congratulated the Consumers Committee on their outstanding workshop at the Power of Quality Improvement Conference and thanked all the Council and committee members and consumers for their outstanding work.
Mr. Powell reported that the new overdose prevention sites have saved over 30 lives so far.
There being no further business, the meeting was adjourned.
Minutes approved by the HIV Planning Council on January 27, 2022
Graham Harriman, MA