Meeting of the Priority Setting & Resource Allocation Committee
Monday, December 11, 2023
By Zoom Videoconference
3:00 – 5:00
Members Present: Paul Carr (Co-chair), Marya Gilborn (Co-chair), Raffi Babakhanian, Matt Baney, Billy Fields, David Klotz, Matthew Lesieur, Guadalupe Dominguez Plummer, John Schoepp, Claire Simon, Terry Troia
Members Absent: Fulvia Alvelo, Kyron Banks, Joan Edwards, Steve Hemraj
Other Council Members Present: David Martin
Staff Present: Doienne Saab, Scott Spiegler, Johanna Acosta, PhD, Adrianna Eppinger-Meiring, Cassidy Burt, Gina Gambone, Frances Silva (DOHMH); Barbara Silver, Arya Shahi (Public Health Solutions)
Agenda Item #1: Welcome/Introductions/Minutes
Ms. Gilborn and Mr. Carr opened the meeting, followed by introductions and a moment of silence. The minutes of the November 13, 2023 meeting were approved with no changes.
Agenda Item #2: GY 2024 Spending Scenario Plan
Ms. Gilborn explained that the Committee develops a methodology for implementing a possible reduction to the grant award so that the Recipient can implement it immediately upon receipt of the full award. The Committee will develop options for a reduction up to 3.5%, as well as a flat-funding scenario to allocate uncommitted funds freed up during the current grant year (2023). The first item for review is the service category of Health Education and Risk Reduction (HER), whose model will be rolled into the new Behavioral Health services that will soon be rebid.
Mr. Lesieur briefed the Committee on Congressional appropriations for Ryan White programs. Current funding continues through February 2, 2024 through a continuing resolution. For appropriations bills, the House of Representatives has proposed level funding for Ryan Whites Parts A, B, C and D. They propose eliminating Part F (dental, AETC, SPNS), as well as Ending the HIV Epidemic funds and MAI funding. The Senate is proposing level funding, which the White House supports. The final result may be either more continuing resolutions or some agreement of appropriations, but for the purposes of RWPA, there should be no change in the national appropriation. In recent years, with level national funding, the NY EMA as lost modest amounts through the formula portion of the Base award.
Health Education & Risk Reduction (HER)
Ms. Burt presented the updated HER fact sheet with data from 2020-2022. The HER category offers an HIV self-management training using one model, known as the Positive Life Workshop (TPLW). Using peers in three programs (one discontinued in 2023), the program is meant to focus on helping those who do not have a suppressed viral load or who do not consistently remain in HIV treatment and care. The client demographics were described (e.g., 97% Black and Hispanic, 56% male, 29% female, 15% TGNCNB), as well as client enrolled from priority populations (e.g., 51% over 50). The number of active clients fell from 602 in 2020 (a drop from the previous year due to COVID) to 498 in 2022. Spending remained level, as the programs used cost-based reimbursement, rather than deliverables-based. The number of service units by type varied, (e.g., increase in the number of workshop units, decrease in client assistance). There are no specific federal payors for HER services for people with HIV. HER is a non-Medicaid billable service that can enhance uptake and engagement in other necessary support and medical services. Staff recruitment and retention continues to be a challenge.
Ms. Burt then presented an evaluation of HER programs with data from 2022. TPLW has seven modules (20 hours total) delivered in English and Spanish through lectures and peer experience groups. In GY 2020, the workshop was given via Zoom due to COVID. The evaluation aimed to describe attendance and completion patterns and assess the effect of the program on ART adherence, viral load suppression and depressive symptoms. Data was collected through eSHARE and matched with viral load data from the NYC HIV surveillance registry.
77% of clients attended at least one module and 83% graduated from less than one workshop cycle. Of those clients, only 19% were not virally suppressed and only 7% were recently diagnosed (with two years). Pre-and post-module and workshop cycle tests were conducted. Of the 382 people who graduated from at least one cycle of TPLW, completed a 3-month follow-up survey on or before 7/31/2023, 97.6% reported being on ART at the pre-test and 3-months later, and had a within one year of pre-test and at 3-months (up from 86.4% pre-test). Viral load suppression did not change between pre- and post-test for most clients but increased some for those from priority populations. Of the 107 individuals who graduated from at least one cycle of TPLW, had ≥1 priority population characteristics, completed a 3-month follow-up survey on or before 7/31/2023, 56% reported being on ART at the start of the cycle, and 94% post-test. Limitations of the study were noted, including the lack of a comparison group (e.g., non-workshop participants).
Ms. Eppinger-Meiering presented options for HER for consideration by the Committee. The Behavioral Health (BH) Service Directive for approved by the Council in June 2023 incorporates a condensed TPLW as a possible evidence-based intervention (EBI) to be provided by agencies awarded through the BH Request for Proposals (RFP) re-procurement process (programs starting March 1, 2025). Another HIV self-management EBI known as the Stanford Model will also be offered. The new program will expand the reach of an HIV self-management program delivered by people with lived experience and expertise, by being rolled into an existing service category and offering a one-stop-shop model for services. They will also include new elements not in the current curriculum (e.g., U=U).
A summary of the discussion follows:
- The data presented was current as of the end of GY 2022 when there were three programs. One program that served mostly clients in Brooklyn rescinded their contract this year, citing staffing issues and difficulty filling multiple vacancies. CTP Quality Management staff provided technical assistance, but it was not enough to overcome their problems.
- If a participant misses more than one session they are discontinued, but it was not clear if there is a pattern of which module is more often when dropouts occur. There is an incentive at the end of the cycle for participants, which encourages clients to complete the course.
- ART adherence is by self-report and there might be bias due to clients wanting to show adherence to higher than expected standards.
- There is no data available on the effect of ART resistance on VLS rates.
- Concern was expressed that as service categories are consolidated that the Council has less input into how they are rolled out. It was noted that the consolidation of the BH categories was a Council initiative, and that separate allocations must still be reported by HRSA service category.
- There are currently 16 Harm Reduction programs and the allocations for HRM, MH and Supportive Counseling are$14M (as opposed to only $585K for HER), so there would be the potential to scale up self-management services under the new directive for a far greater number of programs.
Spending Scenario Plan
Ms. Plummer explained that there is $1,428,678 in uncommitted funds due to contract terminations in HER, Harm Reduction (HRM), Supportive Counseling and Legal Services. Also, due to the rebid of the RWPA Housing portfolio (with programs starting March 1, 2024), a two-month extension is needed for three Housing programs whose contracts end on February 29, 2024 in order to transition their clients to new programs and secure their rent payments and lease agreements. The amount needed for this is $931,956.
Mr. Klotz explained that in a 3.5% reduction scenario, taking into account the need to fund the Housing extension and the savings in carrying costs, there would still be a $2,444,484 deficit. Julie Vara, Director of the HIV Uninsured Care Programs at the NYSDOH AIDS Institute, has assured the Council that ADAP can absorb the remainder of the reduction, given that ADAP will be mostly restored through reprogramming and carryover during the year. If the reduction to the grant award is even more draconian, PSRA can consider a across-the-board cut weighted by service category ranking score. It should be noted that reducing ADAP will make the baseline allocation much smaller and thus there would be far less available in subsequent years to absorb future award reductions.
In a flat funding scenario, after allocating funds for the Housing extension, there would be $496,721 available from the uncommitted funding. One option is to go a one-year enhancement to the Behavioral Health categories (Harm Reduction, Mental Health, Supportive Counseling) so that the allocation for the BH rebid for GY 2025 remains closer to the current allocations for those categories. The Committee can also consider doing a targeted increase based on the GY 2024 application spending request, which allocated additional funds in an increase scenario to Food & Nutrition Services.
Ms. Plummer explained that the reasons for contract terminations are similar across service categories, particularly post-COVID staffing difficulties. While DOHMH can recommend salary levels, they cannot mandate them, and the non-profit sector generally has had difficulty matching the pay and remote work advantages of other sectors. The rescinded HRM program also cited client recruitment difficulties. Administrative burdens have also been cited, and DOHMH has been rolling out ways to reduce burden, including simplifying intake forms.
The Committee will resume the conversation and start making concrete decisions at their next meeting on January 8, 2024.
There being no further business, the meeting was adjourned.