Meeting of the Priority Setting & Resource Allocation Committee
Monday, April 12, 2021
By Zoom Videoconference
3:05 – 4:15
Members Present: Marya Gilborn (Co-chair), Jeff Natt (Co-chair), Fulvia Alvelo, Matt Baney, Paul Carr, Broni Cockrell, Joan Edwards, Billy Fields, Graham Harriman, Guadalupe Dominguez Plummer, Michael Rifkin, Leo Ruiz, John Schoepp, Claire Simon, Dorella Walters
Members Absent: Randall Bruce, Terry Troia
Staff Present: David Klotz, Matthew Feldman, PhD, Melanie Lawrence, Scott Spiegler, Ashley Azor, Eleonora Jimenez-Levi, Kimbirly Mack, Karen Miller, (NYC DOHMH); Andrea Feduzi, Gemma Ashby-Barclay (Public Health Solutions)
Agenda Item #1: Welcome/Introductions/Minutes
Mr. Natt and Ms. Gilborn opened the meeting, followed by introductions and a moment of silence in memory of Terri Smith-Caronia, a long-time advocate for PWH who was remembered for her tireless work for the HIV community, particularly her many years as policy director at HousingWorks. The minutes of the March 8, 2021 meeting were approved with no changes.
Agenda Item #2: FY 2021 Reprogramming Plan
Mr. Klotz presented a draft FY 2021 reprogramming plan for discussion. A reprogramming plan is approved every spring to authorize the Grantee and Master Contractor to reallocate unspent funds (accruals) within the fiscal year to maximize spending. In most years, the first item on the plan is to enhance over-performing programs. This is not feasible as the programs are still being paid through cost-based reimbursement. Also, based on discussions during the recent spending scenario planning, there was a consensus that the priority for this year’s reprogramming be restoring the reduction made to ADAP to cover the cut to the award and new initiatives.
The draft plan gives first priority to restoring ADAP. Should additional funds be available and contracts revert to performance-based reimbursement, the plan allows for the usual authorization to move funds between service categories up to a maximum of 20% of the original allocation (PHS only moves funds between categories after enhancements are done within a category). ADAP is not subject to the 20% cap. ADAP is always able to absorb underspending and fully spend their Part A allocation.
In response to a question, Ms. Plummer explained that DOHMH and PHS make the determination about suing cost- or performance-based reimbursement. She noted that RWPA programs were switched to cost-based even before the City of New York mandated that contracts with all City agencies be switched in response to COVID.
A motion was made, seconded and approved 14Y-0N to adopt the FY 2021 Reprogramming Plan as presented.
Agenda Item #3: Review of Service Category Data
Mr. Klotz outlined minor changes in the timeline for the data review of the RWPA portfolio. After discussions with NYC DOHMH BHIV Research and Evaluation Unit (REU) and CHAIN, the schedule was modified so that Harm Reduction rescheduled to next month. Also, Care Coordination was moved to later in the year. A Fact Sheet will be developed for Non-medical Case Management/Incarcerated, and there will be no meeting in September to accommodate the timing of Council appointments.
Dr. Feldman presented data from an evaluation of the service category of Health Education and Risk Reduction (HERR), starting with some background data on state of the HIV epidemic in NYC, the first Fast-Track City in the U.S. to reach the UNAIDS 90-90-90 goals (90% of all PWH diagnosed, in care and virally suppressed). RWPA services play an important role in helping PWH achieve and maintain VLS by addressing psychosocial and structural barriers to HIV treatment uptake and adherence. HERR is funded at $878,094, which pays for three contracts. The program is a peer-delivered, evidence-based self-management health education curriculum seeking to increase knowledge about HIV care, health topics important to PWH, and medical and psychosocial support services to support and empower people living with HIV to improve their physical and mental health status. The HIV self-management program has 7 modules delivered in English and Spanish, and uses a combination of health education lectures and peer experience groups. While the program is open to all PWH over age 18, the priority population is the newly diagnosed/not linked to HIV medical care/not on or adherent to antiretroviral therapy (ART)/virally unsuppressed.
The goals of the program are to: increase social support; decrease risk behaviors (e.g., substance use); increase active engagement in health care; and improve HIV health outcomes, including ART adherence and viral load suppression. The workshop content and modules were described (HIV 101, engaging in care, physical and mental health, etc.). The HERR evaluation assessed process (e.g., attendance and completion patterns for HERR) and impact (HIV knowledge and beliefs, self-advocacy, ART adherence and VLS). The sources of the data are: Client-level demographic, psychosocial, and service-related data from eShare; outcome data from surveys; and viral load data were from the NYC HIV Surveillance Registry.
From 2015-2019, 2103 people registered for the program and 84% (1360) graduated from at least one workshop cycle. Of these, 38% (537) had one or more characteristics of the priority population. The most common characteristic was unsuppressed viral load (25%), followed by having a recent HIV diagnosis (8%) and/or sub-optimal ART adherence (8%), and not being on ART (2%, n=35). 54% did not have any priority population characteristics.
The outcome evaluation was conducted using a sample of 1360 individuals who graduated from the workshop using pre- and post-test measure on HIV knowledge and beliefs, social support, patient self-advocacy, and ART adherence. Program graduates were predominantly male, Black, and over age 50, over half were unstably housed, and almost one third reported recent depression/anxiety symptoms. TPLW graduates were predominantly male, Black, and over age 50. 59% had a high school education or lower, and 94.5% were already on ART. 47% smoked tobacco, and 11% reported recent hard drug use. A description of the survey questions was given.
There were no significant differences over time for any of the HIV treatment belief items, however, a large proportion of participants entered the workshop with positive beliefs about HIV treatment. There was a statistically significant increase from pre-test in patient self-advocacy, but participants entered the workshop with a relatively high levels of advocating for their health. There was a marginally statistically significant improvement in ART adherence from pre-test to the 3-month follow-up, however in general a high percentage of participants entered the workshop with adherence at or above the level considered necessary to maintain VLS. There was not a statistically significant increase in the percentage of virally suppressed individuals from pre-test to the 3-month follow-up assessment among graduates. Findings for subgroup analysis were generally consistent with those for the overall sample in terms of HIV-related knowledge, beliefs, social support, and patient self-advocacy. Compared to the overall graduate sample, higher proportions of priority population graduates reported symptoms of depression and recent substance use. There was a statistically significant increase the proportion of graduates who reported ≥90% ART adherence. There was a statistically significant increase in the percentage of those who were virally suppressed from pre-test to the 3-month follow-up assessment among priority population graduates.
Overall, the findings suggest that HERR is reaching individuals who are already engaging in the health-promoting behaviors on which TPLW focuses. Even for the outcomes for which there were statistically significant changes over time, pre-test values were fairly high. The program does however seem to increase the level of social support to which people have available to them. For priority populations, the results of the outcome analysis suggest that the program may have a positive effect on improving key outcomes (ART adherence, viral suppression) when the people who may benefit most from the intervention content are reached (acknowledging that these people are harder to reach). This is illustrated by significant improvements in these outcomes in the priority population graduate samples (and the lack thereof in the overall graduate sample). It was noted that high values at pre-test for many of the outcomes make it difficult to see change over time. Workshop content could be revised to address other areas of concern (tobacco, MH). Also, the lack of a control group does not allow us to ensure that any observed changes would not take place without participating in HERR.
A summary of the ensuing discussion follows:
- BHIV has had discussions about revising the curriculum, and will reexamine that after the COVID emergency has abated and fewer staff are activated.
- There is a huge difference between who comes to the program and who we want to come to the program. Priority populations may have greater barriers to engagement (e.g., housing instability). A question to consider is, if it is too difficult to engage the priority population, should the program be tailored to the already highly motivated people who actually show up.
- While it is possible to assess housing and food insecurity as well as domestic violence risk, that would entail an additional set of questions that may be a burden to the providers.
- Programs have made efforts to engage younger people, particularly the newly diagnosed, but it is challenging. As the program is very regimented, it may not appeal to younger audiences.
- It would require qualitative data to measured the impact of people who already self-manage well on the outcomes of people from priority populations, but it is intuitive that the more engaged/treatment adherent group would have an impact by modeling behavior that leads to positive outcomes.
- It is already known that being a peer helps promote positive outcomes for the peers themselves.
- One of the three programs provides incentives (gift cards within HRSA guidelines) upon graduation and for completing the 3-month follow-up.
- For that program, during the first months of the COVID lockdown, they provided ongoing virtual workshops to program graduates. They also adapted the curriculum for Zoom for when the program resumed, compressing the schedule of workshops into 7 days and for a shorter number of hours. They also used a foundation grant to provide tablets on loan to participants and incentives that would help them stay engaged (e.g., paying for WiFi).
- The category is scheduled to be rebid in 2024, and so if the Council maintains the program, IOC would have to consider whether or not to revise the model before then.
- This is one of the best evaluated categories in the RWPA portfolio. A paper will be published soon with findings.
Mr. Klotz added that he will keep a running table that summarizes the findings of all the data reports over the coming year.
There being no further business, the meeting was adjourned.