Thursday, December 17, 2020
By Zoom Videoconference
Members Present: G. Harriman (Governmental Co-chair), D. Walters (Community Co-chair), P. Carr (Finance Officer), F. Alvelo, M. Baney, A. Betancourt, R. Brown, R. Bruce, P. Canady, M. Caponi, E. Casey, B. Cockrell, M. Diaz, M. Domingo, J. Dudley, J. Edwards, B. Fields, R. Fortunato, T. Frasca, M. Gilborn, C. Graham, D. Martin, J. Natt, G. Plummer, D. Powell, J. Reveil, M. Rifkin, L. Ruiz, S. Sanchez, J. Schoepp, F. Schubert, C. Simon, M. Singh, A. Straus, T. Troia, R. Walker
Members Absent: A. Abdul-Haqq, S. Altaf, M. Bacon, D. Beiling, L. Best, R. Chestnut, B. Fenton, MD, B. Gross, A. Lugg, A. Roque, M. Thompson, B. Zingman, MD
Staff Present: DOHMH: D. Klotz, M. Lawrence, A. Azor, A. Guzman, C. Rodriguez-Hart, J. Colón-Berdecía, K. Miller, K. Mack, E. Jimenez-Levi, A. Thomas-Ferraioli, R. Crowley; Public Health Solutions: C. Nollen, B. Carroll, G. Kaloo
Agenda Item #1: Welcome/Moment of Silence/Introductions/Minutes
Mr. Harriman and Mr. Carr opened the meeting followed by introductions and a moment of silence. The minutes of the November 19, 2020 meeting were approved with no corrections.
Mr. Harriman thanked Ms. Nollen and Ms. Thomas-Ferraioli, who will be moving on to new jobs, for their work with the Council on behalf of New Yorkers with HIV.
Mr. Fields acknowledged the Council’s and staff’s dedication over the course of a challenging year and wished everyone the best for 2021.
Agenda Item #2: Recipient (Grantee) Update
Ms. Plummer reported that on November 19, HRSA/HAB released the 2019 Ryan White HIV/AIDS Program (RWHAP) Annual Client-Level Data Report. The report shows that 88.1% of RWHAP clients receiving HIV medical care were virally suppressed, an increase from 69.5% in 2010, and exceeding the national viral suppression average of 64.7% among all people with diagnosed HIV. The report also features RWHAP Services Report (RSR) data on all clients served by the RWHAP during calendar years 2015 through 2019. The data highlight the key role of the RWHAP in providing high-quality care and treatment to more than half a million people with HIV in the USA. The US Department of Health and Human Services also announced the first-ever STI National Strategic Plan.
On December 4th, in response to the service directive approved by the Planning Council, and in advance of a forthcoming RFP, Public Health Solutions (PHS), on behalf of the New York City Department of Health and Mental Hygiene (NYC DOHMH) Bureau of HIV (BHIV), released the Ryan White Part A funded services, Psychosocial Support Services (PSS) for People of Transgender, Intersex, Gender Non-Conforming, and Non-Binary (TIGNCNB) individuals concept paper. A virtual town hall was held to get community input.
On December 8th, over 230 stakeholders, including service providers and consumers, virtually attended BHIV’s 7th Annual, 1st virtual Ryan White Part A (RWPA) Power of Quality Improvement (QI) Conference, with the theme of “Redesigning Systems to Address Social Justice and COVID-19.” A highlight was a Consumer Committee Workshop titled “Consumer Perspectives on Aging, Equity, and Addressing Systemic Barriers to Virtual Services and Telehealth.”
As will be reported later in the meeting, New York City continues to near its goal of ending the epidemic as new infections fell, once again, from 2018 to 2019. Mayor de Blasio and DOHMH Commissioner Chokshi participated in World AIDS Day events, where the Council’s own Lisa Best was honored for her outstanding commitment to ending the HIV epidemic.
Agenda Item #3: Ending the HIV Epidemic Plan: Road to Concurrence
Mr. Harriman gave an update on the implementation of the federal Ending the HIV Epidemic (EHE). As reviewed in previous meetings, NYC has received grants under the US HHS initiative to reduce new HIV infections by 90% in 10 years through activities in broad areas (testing, treatment, prevention, rapid response). The grant requires community engagement, including with local planning bodies leading to a final EHE implementation plan. While grant covers only 4 counties in the EMA as determined by CDC (Staten Island and Tri-County are not included), the plan will help set priorities for the entire EMA.
The draft implementation plan has five fundamental approaches: 1) Improving health services systems; 2) Employing multi-sectoral solutions; 3) Embracing conscious disruption; 4) Empowering community; and 5) Advancing equity. The plan addresses cross-cutting issues around the social and structural determinants of HIV-related health inequities and the HIV Service delivery system. Activities range from working to end stigma to supporting organizations led by people from priority populations to expanding services at DOHMH sexual health clinics.
The five strategies for ending the HIV epidemic were described: 1) Increase the number of people who know their HIV status by diagnosing HIV infection as early as possible, promoting routine testing within health care facilities, and scaling up testing options in non-clinical settings; 2)Prevent new HIV acquisition by increasing access to effective prevention interventions, including PrEP, PEP, condoms, harm reduction, and supportive services; 3) Improve viral suppression and other health outcomes for people with HIV by optimizing medication adherence and access to care, improving coordination of clinical and supportive services, and increasing access to immediate antiretroviral treatment (iART); 4) Enhance methods to identify and intervene on HIV transmission networks to better support people and communities at increased risk of exposure; and 5) In all strategies, utilize an intersectional, strengths-based, anti-stigma, and community-driven approach to mitigate racism, sexism, homophobia, transphobia, and other systems of oppression that create and exacerbate HIV-related health inequities. Priority populations were also described (Black and Latino MSM, Black and Latina women; people of trans experience, youth 13-19, and PWH over 50).
On January 15th, the full draft plan will be circulated to Council members for review. It will be presented at the January 28th Council meeting for final feedback. The Council will vote on concurrence with the plan on February 25th (the HIV Prevention Planning Group will do the same), and the plan will be submitted to the CDC and HRSA on March 31st.
Agenda Item #4: FY 2020 Second Quarter Commitment and Expenditure Report
Mr. Carr introduced the 2nd Quarter Commitment and Expenditure Report for fiscal year 2020 (March 1, 2020 to Feb. 28, 2021). In a normal year, we would have six months of complete data at this point. Due to factors related to COVID and the master contract with Public Health Solutions, the data is not as complete as it normally is. It is important that the Grantee spends the grant according to the Council’s spending plan. The Council’s role is to review spending and ask questions to ensure that the grant is expended according to its plans. Also, it’s this Committee’s responsibility to review the Grantee’s rate of spending. The EMA is allowed to carry-over up to 5% of the award without penalties. For many years, spending rates have been close to 100%, but this is an unusual year. The Grantee team will discuss how they will work to ensure that funds are spent expeditiously with as minimal carry-over as possible.
Ms. Plummer presented the report. Highlights include:
- Spending in the State-Administered Drug Assistance Program (ADAP) is reported at 0% due to late billing submission, which is not unusual.
- Transitional Care Coordination under the Medical Case Management (MCM) service category is not listed here because the funding was reallocated to the Housing Services category by the Council.
- Legal Services spending is low in both NYC (27%) and Tri-County (29%) because courts are closed, and no evictions are happening due to the COVID-19 pandemic.
- RWPA programs in both NYC and Tri-County are underspent due to staff vacancies. Many programs were badly financially hit during the first wave of the COVID-19 pandemic as they could not bill for in-person services and instituted hiring freezes and furloughs. With staff departures and an inability to hire new staff, programs are limited in providing services. Unfortunately, it is not easy to fill vacancies during a pandemic.
- Medical Transportation in Tri-County is at 13% due to the COVID-19 pandemic and the associated shutdowns instituted by the NYS Governor. Clients were not going to providers as often due to limited appointments and the NYS on Pause. Most clients switched their appointments to telehealth resulting in a drastic reduction of transportation usage.
- Emergency Financial Assistance (for the whole EMA, but administered in Tri-County) is at 8% due to the program receiving the $500,000 enhancement in July. It took time to develop a protocol and policies to allow NYC providers to submit referrals. The program is receiving referrals, but they are coming in slowly resulting in underspending. The program has decided to add a part-time position to help with spending the contract down. A potential candidate for this position has been identified and an offer will be made soon.
- Housing programs have reported challenges with placing clients in housing. This is due to delays with HASA and staff vacancies. Updated spending data in Housing shows that 87% of the category is already expended.
- Mental Health Services in Tri-County is at 0% with $97,243 unexpended funds due to staff vacancies and the program not having a Licensed Mental Health Practitioner to provide services. The program is also facing additional challenges with client recruitment and enrollment. The Grantee continues to provide technical assistance to the program.
- The Grantee is scheduled to receive the 3rd Quarter Expenditure Report (expenses through 11/30/2020) in late January.
- The Subtotal of Admin Expenses, at 50%, is on target with the six – month timeline. Quality Management, at 25%, is slightly under target, due to the timing of billing.
In response to questions, Ms. Plummer stated that more complete data will be available with the 3rd quarter report at the end of January. This will give the Council a better understanding about how much the portfolio may fall short of expected spending. Mr. Kaloo added that the Grantee and PHS are continuing to analyze spending so that funds can be reprogrammed according to the Council’s plan. They are also in discussions with the AIDS Institute about how much additional funding the ADAP program can accept, as there is no cap on ADAP enhancements. Also, the Supplemental portion of the award will be spent first, as carry-over from that pool gets deducted from the subsequent year’s award. Mr. Harriman noted that changing or waiving the 5% cap on carry-over of Formula funds requires Congress to act and that advocates are working to ensure that that happens in the appropriations bill.
Agenda Item #5: 2019 NYC HIV Epidemiological and Surveillance Report
Ms. Rodriguez-Hart presented the new NYC HIV Epi and Surveillance Report with data as of Dec. 31, 2019. In 2019, there were 1,772 new HIV diagnoses, an 8% decrease from 2018. However, this number is still short of the ETE goal for 2020 of 1,515 new diagnoses in NYS. 2019 is the second year in a row where the number of new HIV diagnoses has been below 2,000 new cases since reporting began in 2000. New diagnoses decreased for all groups by race, transmission risk, age and borough. New HIV diagnosis rates were highest among Black and Latino/Hispanic men (Black men’s rates were five times higher than white men’s). Black women’s new diagnoses rates are 16 times those of white women’s. This highlights the racial inequities existing for both men and women. There were decreases in new infections among all priority populations (youth, Latino MSM, Black and Latina women, Transgender). New HIV diagnoses decreased among people born in all regions outside of the US. People born in the Caribbean had the highest number of new HIV diagnoses across all years, followed by people born in South America. In terms of new HIV diagnosis rates, people born in Africa had the highest new HIV diagnosis rate across all years, with a 36% decrease seen from 2015 to 2019. From 2015 to 2019, people born in Mexico and Central America had the largest decrease in rate of new HIV diagnoses (47%), while people born in South America had the lowest decrease in rate of new HIV diagnoses (23%). New diagnoses are concentrated in the same high prevalence areas as previous years (Bronx, Central Brooklyn, Upper Manhattan, Chelsea/Clinton).
The report looks at timely linkage to care (are newly diagnosed PWH getting those doctor’s appointments and an appropriate lab done by a provider within 30 days of their diagnosis). While there is a 14% increase in timely linkage to care between 2015 and 2019, there is no increase between 2018 and 2019. The timely linkage data was broken out by demographics, which shows continuing disparities for women, transgender people, Blacks and Asian/Pacific Islanders, people with a history of injection drug use, and youth from 13-19 years old.
Sustained viral suppression has slightly increased from 2018 to 2019, while viral suppression among those in HIV medical care and newly diagnosed remains the same. While the ETE goal of 85% viral suppression for all HIV diagnosed persons has been achieved among those in HIV medical care, more action is needed to attain this goal among newly diagnosed and for sustained viral suppression. Viral suppression rates by demographic groups mirrors those of linkage to care. Using data from the Medical Monitoring Project, we know that inequities in viral suppression by race/ethnicity are exacerbated by different vulnerabilities (poverty, smoking, non-injection drug use, anxiety/depression, binge drinking, and homelessness). The overall care continuum was described. All causes of death among PWH have declined, dropping by more than half since 2003, with a continued decrease in death rates for both HIV-related and non-HIV related causes.
When looking at priority populations of MSM, Women (cis + trans), and younger PWH, there are clear inequities in new HIV diagnoses by race in NYC 2019. Among all women, Black women make up 63% of new diagnoses compared to 28% of Latina women and 6% of white women. Among MSM, Latino men make up 43% of new diagnoses, compared to 37% of Black men and 14% of white men. Similarly, among younger PWH, Latino people make up 46.3% of new diagnoses, compared to 40% of Black people and 9% of White people. there are inequities in linkage to care among newly diagnosed people by race in NYC 2019. Among all women, 100% of white women are linked to care, compared to 82% of Black women and 83% of Latina women. Among MSM, 92% of White men are linked to care, compared to 91% of Black men and 90% of Latino men. Among younger PWH ages 13 to 29, 89% of white people and 90% of Latino people are linked to care, compared to 83% of Black people. There are similar inequities in viral suppression and mortality rates. Across all priority populations, the largest proportion of deaths occurred among Black people (women, MSM, and younger), Latina women, and younger Latino people. Given similar inequities for new HIV diagnoses, linkage to care, and viral suppression, active steps must be taken to further engage and retain these communities in care.
A summary of the ensuing discussion follows:
- Possible reasons for why people over 60 have lower rates of linkage to care but higher rates of viral suppression are that for people who do not think of themselves as high risk for infection may take time to adjust. Also, if someone is diagnosed while in inpatient care, there can be a delay.
- It can be difficult to track when someone moves out of NYC, but lab results are used as proxies, and health departments notify other health departments.
- The category of “other” race/ethnicity does not include people who identify with more than one (e.g., Latino/Black).
Agenda Item #6: Policy Update
Mr. Guzman presented an update on HIV-related law and policy issues. Topics covered included: 2020 election, COVID activity, Co-pay accumulators, and World AIDS Day. President-elect Biden’s health team includes HHS Secretary Xavier Becerra, Surgeon General Vivek Murthy and CDC Director Rochelle Walensky. Dr. Anthony Fauci will be chief COVID Medical Advisor. There was an update on the COVID vaccines and the NYC vaccine website. Also, the US HHS HIV National Strategic Plan 2021-25 was recently released and it included New York’s recommendations, particularly around the use of a status-neutral continuum of care.
Co-pay accumulatorsarestrategiesused by insurance companies and pharmacy benefit managers to prevent drug manufacturer co-pay assistance coupons, patient assistance program (PAP) payments, or other third-party assistance from counting toward a beneficiary’s deductible or the plan’s annual out-of-pocket maximum. Insurers can collect these initial payments and then demand and collect additional deductible payments from the beneficiary after the co-pay assistance runs out. This can result in more out-of-pocket payments for people whose health plans use co-pay accumulators, which can lead to interruptions in treatment or stopping treatment altogether. In May 2020, the Centers for Medicare and Medicaid Services finalized a rule explicitly allowing certain health plans to determine – in accordance with state law – whether to count drug manufacturer coupons and PAP payments toward the plan’s annual limit on cost-sharing. Currently, in New York State, a health plan can use co-pay accumulators. Legislation was introduced in January 2019 to limit the practice, but the bill has not left committee. Given the very high cost of HIV medications, including PrEP, many people with HIV or at increased risk of acquiring HIV depend on drug manufacturer co-pay assistance coupons, PAP payments, or other third-party assistance to help bring down their prescription drug cost sharing.
There being no further business the meeting was adjourned.
Minutes approved by the HIV Planning Council on January 28, 2021.