Planning Council Meeting Minutes December 19, 2019

Meeting of the

HIV HEALTH AND HUMAN SERVICES PLANNING COUNCIL OF NEW YORK

Thursday, December 19, 2019

3:05-5:00 PM

LGBT Center, New York, NY

M I N U T E S

Members Present: M. Lesieur (Community Co-chair), A. Abdul-Haqq, L. Best, A. Betancourt, R. Bruce, R. Chestnut, M. Domingo, J. Dudley (by phone), R. Fortunato, T. Frasca, C. Graham, B. Gross, G. Harriman, C. Kunzel, Ph.D. (by phone), O. Lopez (by phone), A. Lugg, J. Maldonado, M. Mañacop, J. Natt, D. Powell (by phone), M. Rifkin, L. Ruiz, J. Schoepp, F. Schubert (by phone), S. Serafino (for E. Casey), C. Simon (by phone), A. Straus, T. Troia (by phone) , D. Walters, B. Zingman, MD (by phone)

Members Absent: M. Bacon, F. Barrett, D. Beiling, P. Canady, P. Carr, B. Cockrell, M. Diaz, J. Edwards, B. Fenton, MD, S. Hemraj, J. LiGreci, M. Mackey, J. Reveil, C. Reyes, A. Roque, M. Singh, M. Thompson, R. Walker

Staff Present: DOHMH: D. Klotz, M. Lawrence, C. Rodriguez-Hart, J. Colón-Berdecía, A. Thomas-Ferraioli, K. Mack, T. Gardet; Public Health Solutions: B. Carroll, G. Kaloo

Guests Present: S. Caputo (Bannon Consulting)

Jesse Thomas (RDE Systems): I have worked on Ryan White and HOPWA for over a decade and am happy to offer a suite of free apps for the Council and other users that can help with community engagement, data collection and other purposes.

Daniel Castellanos: I am working for DOHMH to develop a resource guide for older PLWH, including conducting interviews and holding a summit for Latino Gay men on developing a new generation of sexual health services.

Agenda Item #3: Recipient (Grantee) Update

Mr. Harriman reported that HRSA announced that the Ryan White HIV/AIDS Program Annual Client-Level Data Report, 2018 is now available on the HAB website at http://hab.hrsa.gov/data/data-reports.

The publication provides an in-depth look at demographic and socioeconomic factors among clients served, including age, race/ethnicity transmission risk category, federal poverty level, health care coverage, and housing status. In addition, retention in care and viral suppression data are presented for the overall RWHAP client population receiving medical care, as well as among key priority populations served by RWHAP.  The 2020 National Ryan White Conference, the largest national conference for comprehensive HIV care and treatment providers, will take place on August 11 -14, 2020, in Washington, DC.

The estimated unobligated balance request, approved by the Council last month, was submitted to HRSA on December 12^th.  On Monday, November 25, 2019, over 200 stakeholders including services providers and consumers of services for people living with HIV, attended BHIV’s 6th Annual Ryan White Part A (RWPA) Power of Quality Improvement (QI) Conference at New York University.  An award for the First Time Oral Presenter was given to Mr. Schubert, who presented “Supporting timely linkage to care for newly diagnosed and previously diagnosed individuals living with HIV.”

On World AIDS Day, Health Commissioner Dr. Oxiris Barbot announced that New York City has reached the UNAIDS 90-90-90 targets two years ahead of schedule, meaning that 90% of all people with HIV know their status, 90% of all people diagnosed with HIV are on treatment, and 90% of all people diagnosed with HIV who are on treatment are virally suppressed. As of 2018 in New York City, 93% of people with HIV have been diagnosed, 90% of people diagnosed with HIV are on treatment, and 92% of people on treatment are virally suppressed.  NYC is the first large Fast-Track City in the U.S. to reach the milestone.  The same day, the End AIDS NY 2020 Coalition, a group of over 60 community partners from across New York State, in conjunction with the New York State Department of Health and NYC DOHMH, hosted the World AIDS Day 2019 citywide event at New York Academy of Medicine on Manhattan’s Upper East Side.  The event’s theme, CommUNITY, highlighted the importance of meaningful community input in developing and implementing plans to end the epidemic.  DOHMH also sponsored its sixth annual RED Ball, co-hosted by the Kiki Coalition.  This year’s theme, RED Revolution, celebrated revolutionaries of the LGBTQ community who fought for civil rights and liberation, and who inspire today’s activists to bring forth a new revolution to end the HIV epidemic in NYC.

New York Knows, launched on World AIDS Day 2014, represents a partnership between the Health Department and community-based organizations, community health centers, hospitals, colleges and universities, faith-based organizations, and business to: provide a voluntary HIV test to every New Yorker; routinize HIV testing in health care; identify undiagnosed HIV-positive people and link them to care; and connect people at risk of HIV care.  Building on this success and after careful consultation with community partners, DOHMH announced on World AIDS Day that New York Knows will continue for another five years through World AIDS Day 2024.  Moving forward, New York Knows will embody an HIV status neutral approach to prevention and treatment, ensuring that all New Yorkers receive quality care and services, regardless of HIV status.

Mr. Harriman reviewed the City’s timeline for implementation of its Ending the HIV Epidemic initiative, which builds on the NYS EtE Blueprint.  BHIV has received funding from the CDC (Grant 1906) to support strategic partnerships and planning to support ending the HIV epidemic in the United States. The BHIV funded project seeks to improve the Health Department’s ability to rapidly implement activities to meet identified jurisdictional needs and meet or exceed the national prevention and care goals by leveraging existing planning processes and bodies.  Work is being done on a plan that must be submitted to CDC, which builds on the State ETE blueprint.  A more detailed presentation will be done at a future meeting, as the Council will be providing input be asked to concur with the plan.  The 1906 grant is a planning grant and part of a larger Notification of Grant Opportunity (NoFo) that includes care and prevention funds, which were just included in the budget approved by Congress.

Agenda Item #4: Committee Updates

Consumers Committee

Mr. Bruce and Ms. Best reported that the Consumers Committee met on Tuesday and debriefed from its successful session on “Meeting Client Needs for Oral Health Services” held at the November 25^th Power of Quality Improvement Conference.  There were over 40 participants – a record number.  The session began with a panel of three presenters: Angela Aidala (CHAIN); Dr. Judy Moy (Mount Sinai); and Gregg Bruckno (GMHC Long-term Survivors Hub). They presented data on oral health utilization, the importance of oral health as part of overall health for PLWH, and discussed barriers to accessing oral health care.  The panelists were all very well received and generated a large number of questions from the audience.  After the panel, participants broke out into small groups facilitated by committee members.  Groups brainstormed what intake questions should be added to Ryan White Part A programs’ intakes so that providers can assess and make referrals for oral health services.  Other groups brainstormed what service elements should be included in the Oral Health Service directive that the Planning Council’s Integration of Care Committee will develop in 2020.  Participants filled out an evaluation and rated the session very highly.  Overall, they found the session highly informative and relevant.  Committee members who helped organize the session were acknowledged, particularly Mr. Carr who led the QI Conference Sub-committee and spearheaded this effort.

At Tuesday’s meeting, the committee also brainstormed ideas that the Committee may address in 2020.  Among the ideas developed are: HIV and Aging – services that can reduce social isolation help people live independently); Providing Consumer input to enhance the new Council website; Emergency Financial Assistance; Participating in a new anti-Stigma Initiative; and others.  Before the January meeting, the Committee will vote to prioritize these ideas and then begin to flesh out the higher ranked priorities.

Needs Assessment Committee (NAC)

Ms. Lugg reported that NAC subsumed the work of their Seriously Mentally Ill subcommittee at the beginning of this planning session.  The committee has spent the last few meetings getting up to speed and receiving presentations, including one from the DOHMH’s Research and Evaluation unit on engagement, retention in care and viral suppression for Ryan White clients with a Mental Health Diagnosis.  Next month the committee will view the results of a match between a DOHMH Bureau of Mental Health database of people with serious mental illness and the HIV surveillance registry.

Integration of Care Committee (IOC)

Mr. Powell reported that IOC has made incredible headway in the process of completing the editing of the Standards of Care.  These documents serve as a sort of “recipe” for each service category.  This long process has helped identify key areas for council focus for when the master directive is amended.  In January IOC will push ahead with the development of an Oral Health service category for NYC, building on the work of the subcommittee that operated last planning session.  IOC will look at the Tri-County’s Oral Health directive as a model.

Tri-County Steering Committee

Ms. Straus reported that The Tri-County Steering Committee has held two meetings since the beginning of the planning cycle.  The committee completed its FY 2020 spending scenario, which was forwarded to the PSRA Committee for review and approval.  Since the TC portfolio was rebid last year and programs are in their startup year, there is no change to the carrying cost of programs.  The one exception is the Housing Services Category.  In 2019, TC Housing programs enrolled more clients than the program was budgeted for.  Also, there was a demand for a larger number of family units in contrast to single individuals, thus the programs’ rental assistance share was higher than anticipated.  The shortfall was covered in FY 2019 through the use of carry-over funds left over from FY 2018.  Those carry-over funds run out on February 29, 2020.  In order to keep those extra clients housed in 2020, the Steering Committee requested an increase to the baseline Housing allocation of $175,000. 

The Committee also celebrated the retirements of Julie Lehane and Jan Park, who were an integral part of the Tri-County HIV community.  In January, we will have a presentation from Ms. Thomas-Ferraioli to help committee members develop civic engagement and advocacy strategies around HIV and other issues in the Tri-County region. 

Priority Setting & Resource Allocation Committee (PSRA)

Mr. Natt reported that PSRA met last week to begin scenario planning for a possible decrease to the FY 2020 grant award.  This is a process that the PSRA and Council undertake every year to develop a methodology that the Grantee can use to implement the Council’s priorities immediately upon receipt of the grant award.  The Committee reviewed and approved the Tri-County Steering Committee’s 2020 spending request.  PSRA then began the effort to determine an allocation for the new service category approved last July by the Council for Psycho-social services for people of Transgender, Intersex, Non-binary and Non-conforming experience.  Members re-reviewed the service model and elements, which includes both direct services, a resource directory of places to get gender-affirming care, and a training curriculum.  The resource directory and training curriculum can be implemented in 2020 and PSRA approved $50,000 for that (with the expectation that $10,000 per year will be needed in subsequent years for updates).  This amount was based on the time and effort that has been required for similar projects.

The request for proposals process for the direct services portion of the new category means that the services will be in place in 2021.  PSRA reviewed epi data and several cost analyses, and began a robust discussion on how many programs could be funded and at what cost.  PSRA will continue this discussion at its January meeting with additional data, such as geographic distribution of transgender PLWH.  We hope to have a final recommendation for the Executive Committee and full Council by the January meeting, where we will present a full spending scenario for final approval.  At the January meeting, PSRA will also have data on the carrying costs of the service portfolio into 2020.  There is always some savings in the cost of existing programs, which can partially offset the reduction to the grant award.  We expect, as in previous years, to cover the remaining deficit, as well as the cost of any enhancements and new programs, by reducing the allocation to ADAP.  Julie Vara, the ADAP Director at the AIDS Institute, has confirmed that the State can absorb a reduction to ADAP without losing any services through other funding streams (Part B, State funds, drug rebates).  It was noted that the budget just passed by Congress flat funds Part A programs.  This means that the NY EMA will continue to see reductions in its formula award (which is 2/3 of the Base award), because of the decline in the rate of new infections in comparison with the rest of the country.  Also, it is unknown how the funds appropriated for Ryan White under the federal Ending the HIV Epidemic initiative will be allocated to the priority areas and for how many years and at what amounts.

Agenda Item #5: 2018 HIV Surveillance Report

Ms. Rodriguez-Hart presented on the recently released 2018 NYC HIV surveillance report (data for Tri-County is maintained by NYSDOH and will be presented at a future meeting by NYSODH).  In 2018, there were 1,917 new HIV diagnoses – this is the first time under 2,000 new diagnoses since HIV reporting began in 2000.  There were zero perinatal transmissions –this is the second time this has happened since surveillance of HIV-exposed births began in NYC.  There were 1,214 new AIDS diagnoses and 1,683 deaths among people with HIV.  New diagnoses have decreased by 29% over the past 5 years.  One exception is that new diagnoses among transgender people increased by 5% from 2017 to 2018.  Although new diagnoses decreased by 29% in the five year period, transgender people only saw a decrease of 9% and PLWH ages 50+ saw a decrease of 16%.

HIV rates (diagnoses in relation to the size of the population) show that new HIV diagnosis rates were highest among Black and Latino/Hispanic men (5 times higher than the rates among White, Asian/Pacific Islander and Native American Men).  Inequity is even more stark for women, where rates for Black and Latina women were 11 times higher than for white or Asian women.

Geographic distribution of HIV diagnoses has remained stable, with Chelsea/Hell’s Kitchen, Upper Manhattan, South Bronx and Central Brooklyn showing the highest rates.  However, Chelsea/Hell’s Kitchen has a much higher rate of viral suppression and lower death rate.  55% of new HIV diagnoses were among people born in the US. Considerable variability in diagnosis rates existed across sub-regions of birth. Most African regions had the highest rates.

From 2014 to 2018, there was an increasing number of newly diagnosed people who have an appropriate lab test done by a provider within 30 days of their diagnosis.  Overall sustained viral load suppression (VLS) was 67%.  While we are doing better as a whole, we see that some of the inequities in our society are reflected in sustained VLS numbers (lower percentage suppression among: Transgender people, Black  and Latino/Hispanic people, people in younger age groups, and people who have a history of injection drug use).  Among people newly diagnosed with HIV in 2018, Black cisgender women had the lowest timely linkage to care and they had the smallest increase since 2014 (7%).

In 2018, it’s estimated that 77% of all people living with HIV (diagnosed and not diagnosed) were virally suppressed.  There has been a 104% increase in people with timely viral suppression (within three months of diagnosis).  There are lower timely VLS rates among cis women, transgender people, blacks, whites, 13-19, ages 50+, people who inject drugs, heterosexual people, and those of unknown risk.  Among people in HIV care, the percent suppressed went from 81% in 2014 to 87% in 2018.  In 2018, women, transgender people, Black people, adolescents 13-18, people living in their 20S, 30s and 40s, and people whose transmission risk was IDU, MSM-IDU, heterosexual contact, TG-SC, and other had lower viral suppression.  Similar racial/ethnic inequities were seen in viral suppression for PWH ages 50+, PWH ages 13-29, and transgender PWH. Black people had the lowest viral suppression across the 3 priority populations.  In 2003 the percentage of deaths due to HIV was 63% of mortality among people with HIV. This dropped to 28% in 2017.

The extensive data security measures were also detailed, including both physical and electronic security.  There are severe protocols for any data breach.

A summary of the discussion follows:

• Time from initiation of treatment to VLS varies, depending on adherence and the patient’s viral load, but under ideal conditions, VLS can be achieved within one month.
• The total number of PLWH is based on a CDC model that uses CD4 count at diagnosis, estimating the time from infection.  The number of those who have been diagnosed is exact, as each test result is reported to DOHMH.
• Some causes of death that are listed as non-HIV-related could actually be related to living with HIV long-term or long-term use of medications (e.g., coronary artery disease). 
• There have not been increases in new infection rates by geography. 
• CD4 counts are still reported, but the Surveillance data also considers VLS and genotype now to get a fuller picure of the epidemic.

Agenda Item #6: FY 2020 Grant Application

Mr. Harriman introduced Ms. Caputo, noting that Bannon Consulting has worked on the EMA’s grant application for 5 years.  The application process is a huge, extremely complex task, which they manage with the utmost professionalism.

Ms. Caputo presented highlights from the FY 2020 Grant Application, which was submitted to HRSA in September.  The Care and Treatment Program (CTP) team leads the application process, with coordination support from Bannon Consulting Services. The application is developed by CTP with contribution from: the BHIV (HIV Prevention Program, Policy and External Affairs, Epidemiology and Field Services Program), plus input from DOHMH Bureau of STI and Viral Hepatitis Program, the Planning Council staff, New York State DOH AIDS Institute, and Public Health Solutions.  After the application is released, the team has 3 months to develop the narrative (which goes through 4 drafts), budget, and attachments.  Total HIV services funding requested for FY2020 was $ 86 million.  The broad elements of the applications were: Needs Assessment, Early Identification of Individuals with HIV/AIDS (EIIHA), Methodology, Planning Responsibilities, Workplan, Resolution of Challenges, Evaluation and Technical Support Capacity, and Organizational Information.

The Needs Assessment section provides an overview of the HIV epidemic in the EMA (NYC and Tri-County), which includes 131,076 PLWH; 13% of all PLWH in the US (s of June 2019).  A brief epidemiological overview was provided for NYC and Tri-County.  The application summarizes co-occurring conditions that affect the populations served: Hepatitis C (11% of PLWH in NYC were living with HCV by Dec 31, 2018); STIs such as Syphilis, Gonorrhea, and Chlamydia, which increase the risk of sexual HIV transmission; Mental Illness (among NYC RWPA clients served in 2018, 23% screened positive for depression and 25% for anxiety); Substance use (among RWPA clients served in 2018, 18% of those assessed reported recent hard drug use and only 66% of those were virally suppressed, compared to 83% of those who did not report recent hard drug use); Homelessness (during the most recent CHAIN survey period of 2017-2019, 30% of the NYC cohort, and 15% of the Tri-County cohort were homeless or unstably housed); Formerly Incarcerated (over two-thirds of NYS inmates return to NYC and reside in seven ZIP codes located in Central Brooklyn, Central and East Harlem in Manhattan, and the South Bronx); Tobacco (an analysis conducted by the NYC Health Department found that recent tobacco smoking was reported by 39% of PLWH enrolled in RWPA programs and recent tobacco smoking was independently associated with low CD4 cell counts and unsuppressed viral load).

The Care Continuum shows that the EMA surpassed national goals for knowledge of HIV status (90%) and linked to HIV medical care (85%).  The EMA is working towards reaching national goals for retention in care (90%) and viral load suppression (80%).  The EIIHA section outlines the NY EMA’s overall plan to identify individuals with HIV and link them to care.  The pillars of the plan are to: promote and increase HIV testing through its Status Neutral Navigation approach; 2) improve linkage and retention efforts; and increase awareness and referral to prevention services (including PrEP/PEP).  Based on the epidemiological data and dipartites within the care continuum, Ryan White programming will focus on serving the following priority populations: Young Black and Latino men who have sex with men (MSM); Transgender, gender non-conforming, or non-binary (TGNC/NB) persons and their partners; and Black women in high prevalence areas.

The Methodology section discusses how changes in healthcare coverage effect both PLWH’s access to care and RWPA programming.  Issues addressed include: the impact of the changing healthcare landscape, and the effects of the changing healthcare landscape on RWPA allocations.  As a result of so many PLWH having access to medical insurance, NY EMA’s Ryan White programming can focus on funding supportive service programs, especially Housing, Food and Nutrition Services (FNS), and Psychosocial Support Services (PSS).

The Application details how the Council utilized data-driven planning tool to develop service priorities and determine funding allocations based on PLWH needs, service utilization, and gaps.  Data inputs included as the NYS Integrated HIV Prevention and Care Plan, Payer of Last Resort (POLR) Analysis and Service Category Fact Sheets. The Completed FY 2020 allocation request in the application allocates 56.2% of Base and MAI funding to Core Medical Services (CMS) and approved increases in targeted service categories to address funding reductions from previous years and address ongoing needs of PLWH.

The Workplan details initiatives to address unmet need and improve the EMA’s performance across the Care Continuum, such as a surveillance-based client-level viral suppression progress report and a protocol to implement a value-based payment model across the Care Coordination Program to incentivize quality improvement among sub-recipients.  In FY2020 the NY EMA will work to resolve a number of challenges to address the needs of priority populations: Older PLWH, PLWH with Disabilities, Homeless and Unstably Housed PLWH, Diagnosis & Linkage to Care, Culturally Competent Care, and Health & Racial Equity.

The Clinical Quality Management (CQM) program works to sStrengthen RWPA providers’ capacity for QM by providing guidance in program model implementation and improve care across the continuum.  The application outlines the assessment of the administrative mechanism (in FY2018, the EMA spent more than 99.72% of its Base award and 100% of its MAI award).

In response to a question about the lack of data on income, it was noted that proxies were used (e.g., Medicaid eligibility).  The average RWPA client earns less than the federal poverty level.

Agenda Item #7: Public Comment

Ms. Best thanked the Council staff for their support of the Consumers Committee.

Mr. Lesieur announced that for future meetings, closed captioning will be available upon request, similar to the way ASL and foreign language interpretation is currently provided. 

There being no further business the meeting was adjourned. Minutes approved by the HIV Planning Council on January 30, 2020