Priority Setting & Resource Allocation Committee Minutes May 10, 2021

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Meeting of the Priority Setting & Resource Allocation Committee

Monday, May 10, 2021

By Zoom Videoconference

3:05 – 4:45

Members Present: Marya Gilborn (Co-chair), Jeff Natt (Co-chair), Fulvia Alvelo, Matt Baney, Randall Bruce, Paul Carr, Broni Cockrell, Joan Edwards, Billy Fields, Guadalupe Dominguez Plummer, Michael Rifkin, Leo Ruiz, John Schoepp, Claire Simon, Dorella Walters

Members Absent: Graham Harriman, Terry Troia

Staff Present: David Klotz, Matthew Feldman, PhD, Melanie Lawrence, Scott Spiegler, Jennifer Carmona, Frances Silva, José Colón-Berdecía, Kimbirly Mack, Karen Miller, Giovanna Navoa (NYC DOHMH); Andrea Feduzi (Public Health Solutions); Angela Aidala (CHAIN)

Agenda Item #1: Welcome/Introductions/Minutes

Mr. Natt and Ms. Gilborn opened the meeting, followed by introductions and a moment of silence.  The minutes of the April 12, 2021 meeting were approved with no changes.

Ms. Simon reported that Alliance for Positive Change and Housing Works are coordinating a memorial for Terri Smith-Caronia, with details to be announced.  Mr. Carr suggested that the Committee revisit the $2000 annual cap per client on the use of Emergency Financial Assistance due to the ongoing problems caused by COVID and the possible lifting of eviction moratoria.  Ms. Lawrence encouraged everyone to attend (and recruit consumers to attend) the June 4th virtual forum on Older PWH, which will focus on a draft service directive to address the needs of this population.  

Agenda Item #2: Review of Service Category Data: Harm Reduction (HRM)

Dr. Feldman presented data on substance use among Ryan White Part A (RWPA) enrollees and among enrollees of HRM programs.  The study period was FY 2017 with data from enrollments, intake assessments, reassessments, and services that were entered into eSHARE.  Included were clients who had all of the following: 1) an open HRM enrollment; 2) a completed HRM intake assessment; and 3) one or more HRM services.  Across the 17 HRM programs funded during the period of interest, there were 1705 enrollments, representing 1555 unique clients.  As of the end of the grant year, about 63% of enrollments were still open with an average enrollment length of 326 days. Closed enrollments had an average enrollment length of 186 days.  The majority of HRM clients were male, over age 50, and Black.  

Only individuals with a valid response to both lifetime and recent use were included in the denominator of lifetime use.  Alcohol, tobacco, and marijuana were the most commonly reported substances among HRM clients in terms of lifetime and recent use.  Any alcohol use would qualify someone to be included, but a relatively small percentage of HRM clients were heavy drinkers.  The percentage of clients with 6 or more substance use services (individual, family or group alcohol/drug counseling, Healthy Living Project, Seeking Safety, and Overdose Prevention Training) during a quarter declined from 65% to 52%.  

Dr. Feldman also presented on crystal meth use and HIV health outcomes among MSM in RWPA programs.  This was an important population on which to focus, particularly in the context of research that has shown HIV-infected MSM have reported elevated rates of crystal meth use and that rates of crystal meth use are significantly higher among HIV-infected MSM (19%-32%) compared to HIV-negative MSM (12%-17%).  The aim was to examine the differences in sociodemographic and clinical characteristics between HIV+ MSM with and without recent crystal meth use, and to examine the relationship between crystal meth use and HIV medical outcomes (unsuppressed VL, low CD4 counts) in this population.  The population for this study included 2896 HIV+ MSM who received RWPA services in the New York metropolitan area between Nov. 2010 and June 2012.  To be eligible for inclusion in this sample, individuals must have completed at least one substance use assessment and had to have a viral load and/or CD4 count in the NYC HIV Surveillance Registry with a test date in the three months prior to the most recent assessment.

HIV-infected MSM who reported recent crystal meth use were more likely to be: under the age of 30, white, have a high school education or more, unstably/temporarily housed, have reported recent cocaine/crack use, not have a current prescription ART, virally unsuppressed, and have lived for fewer years with HIV.  There was an independent association between recent crystal meth use and unsuppressed VL after controlling for the variables that were associated with unsuppressed VL in the analyses.  However, recent crystal meth was not associated with low CD4 counts.  The proportion of HIV-infected MSM who reported crystal meth use (4%) was somewhat lower compared to those reported in other studies of this population that range from 10%-23%.

Dr. Feldman also reported on associations between drug use patterns and viral load suppression among HIV-positive individuals who use support services in New York City.  The study aim was to describe drug use patterns among HIV-infected individuals receiving Ryan White Part A (RWPA)- funded support services in New York City, to examine sociodemographic and clinical characteristics associated with particular patterns of drug use, and to identify any independent associations between drug use patterns and unsuppressed VL.  The study looked at 7,896 PWH who matched to the Registry and completed at least three substance use assessments in eSHARE and met other specific criteria.  The study assessed the following patterns of use: Persistent use(hard drug use reported on every assessment); Intermittent use active at 3rd assessment(hard drug use reported on the third assessment but not all previous ones); Intermittent useabstinent at 3rd assessment(hard drug use reported previously with no HDU reported on the third assessment); and Persistent non-use (no reports of hard drug use on any assessment).

The most commonly reported hard drug was crack/cocaine for both lifetime and recent use.  Of the drug use patterns, intermittent use, abstinent at 3rd assessment was most common.  Compared to persistent non-users, drug users were more likely to be: transgender; between 30 and 49 years old; educated at less than the high school level; born in the US/US territory; primarily English speaking; living below the federal poverty level; unstably housed; and receiving RWPA harm reduction services.  All three types of hard drug use were independently associated with unsuppressed VL, with persistent use the most strongly associated.  There is a significant, independent relationship between drug use patterns and unsuppressed viral load assessed at a later point in time.  Findings underscore the importance of recent drug use as a factor to evaluate and address regarding HIV treatment engagement.

Key findings are: Smoking cessation programs are a key service for people living with HIV(high proportions of HRM clients reported lifetime and recent tobacco and marijuana use); Cocaine and crystal meth use should be addressed among HIV-positive MSM receiving RWPA-funded services(cocaine/crack and crystal meth use were associated with unsuppressed viral load in this population); Strategies are needed to engage individuals who use drugs intermittently(persistent and intermittent drug use patterns were significantly associated with unsuppressed viral load).

A summary of the ensuing discussion follows:

  • The data presented was the most recent available.  REU staff has not been able to perform any additional analyses in the past year due to staff vacancies and almost complete activation for the COVID response.  
  • A big open question will be the effect of the COVID pandemic on both drug use and service utilization.  There are anecdotal reports of both increased drug and alcohol use during the pandemic and uncertainty if that increase will abate as the pandemic recedes.
  • Alcohol use is a focus for CTP, as there is strong evidence that problem alcohol use (which is highly prevalent) is linked to lower VLS.
  • Meth use can be underreported as some users are linked online.  
  • More information on this could gleaned through qualitative data obtained through interviews (a time-consuming process, as many interviews would have to be conducted to ensure that the data does not reflect a small sample).
  • Adding qualitative questions to eShare will add burden to both providers and clients for what is already a long list of questions (the intake assessment is 11 pages long).
  • There are broader payer of last resort issues: Medicaid coverage for harm reduction services, other funding (e.g., new funding from the federal government – $30M nationally through the most recent COVID stimulus for harm reduction).
  • During a COVID check-in, CHAIN participants reported both increased and decreased use of substances as well as utilization of HRM services.  
  • There has been some reporting that there is a shift in crystal meth use in recent years from mostly white people to more people of color.

Dr. Aidala presented on substance use among CHAIN participants: patterns of use (including by demographics) and substance use patterns and engagement with HIV care, adherent ARV use and viral suppression.  The study measured: problem drinking/drug use, current and problem hard drug use (opiates, amphetamines, etc.), and injection drug use.  The study looked at the effect of those on engagement in Care and viral load outcomes (consistent care, ARV adherence, VLS).  In the NYC CHAIN cohort, 11% report current problem drinking, 22% problem substance use, 15% current hard drug use, and 3% current injection drug use.  This was further broken down by substance (e.g., 35% current marijuana use, 6% current meth use), and frequency (39% use alcohol weekly or more, 40% marijuana, 11% cocaine/crack, 4% heroin, 10% meth).  

The analysis showed that: problem drinking decreases with age; hard drug use was most common among those 35-49 years old; older PWH (age 50+) are the most likely to report a history of IDU but very few respondents currently use needles for any substance; more men than women have a history of problem drug use as well as IDU, and a higher percentage are current problem substance users; rates of problem drinking are higher among Black/Latinx respondents while rates of current hard drug use higher among white respondents; and current problem substance use is more common among PWH unstably housed or homeless.    

Substance use demographics were provided by age, race/ethnicity, gender, housing status, poverty level and borough of residence.  Problem drinking and hard drug use were most common among younger respondents (18-34 years); more men than women have a history of problem drug use as well as IDU, problem drinking and current problem drug use was most commonly reported by Latinx respondents, and rates of problem drinking and current problem substance use are higher among persons who are unstably housed/homeless. 

Concerning care and treatment outcomes, problem drinkers and current marijuana users more likely than non-users or former users to have low mental health functioning scores.  Problem drinkers have lowest rates of consistent HIV care and are less likely to be adherent ARV users.  Current problem substance users have worse outcomes than non-users or former users regarding mental health functioning, continuous HIV care, adherent ARV use or viral suppression.  Participants reporting any IDU have worst outcomes on all indicators of engagement in care and health outcomes although relatively few active needle users are in the study sample.

In summary, a history of problem substance use is widespread – more than half of study participants have a history of problem drinking and/or hard drug use.  Problem drinking is more consistently associated with worse engagement in care and health outcomes than current marijuana use.  Current problem substance use – problem drinking or hard drug use – is one of the strongest predictors of poor engagement with care and health outcomes among PWH.  Current problem substance use is associated with lower odds of continuous care, adherent ARV use, and viral suppression controlling for a range of client characteristics and other service needs and services received.

In response to a question, Dr. Aidala reported that in the COVID check-in survey, 6-8% of respondents reported increased substance use during the pandemic.  It was also added that CHAIN asks about the use of 12-step programs and may be able to assess their impact.

Ms. Gilborn noted that the chairs and staff will make sure the Committee loops back to discuss the unanswered questions, including eShare and payer of last resort issues.

There being no further business, the meeting was adjourned.