2. Ending the Epidemic in New York State
Mid and Lower Hudson New York
Regional Group March 2nd, 2018
WELCOME
Chat Room Question
What improvement ideas to you have to advance linkages and retention across agencies and providers?
Ending the Epidemic in New York State 2

3. Welcome

4. Ending the Epidemic Defining the “End of AIDS”
A 3-Point plan announced by the Governor on June 29, 2014
Identify all persons with HIV who remain undiagnosed and link them to health care.
Link and retain those with HIV in health care, to treat them with anti-HIV therapy to maximize virus suppression so they remain healthy and prevent further transmission.
Provide Pre-Exposure Prophylaxis (PrEP) for persons who engage in high-risk behaviors to keep them HIV negative
Reduce the number of new HIV infections to just 750 [from an estimated 3,000]
by 2020

5. Public Release of the Blueprint
April 29, 2015
We must add AIDS to the list of diseases conquered by our society, and today we are saying we can, we must and we will end this epidemic ~Governor Cuomo

6. Blueprint Recommendations (BPs)
Link and retain persons diagnosed with HIV in care to maximize virus suppression so they remain healthy and prevent further transmission.
BP5: Continuously act to monitor and improve rates of viral suppression BP7: Use client-level data to identify & assist patients lost to care or not virally suppressed BP8: Enhance & streamline services to support the non-medical needs of persons with HIV...
BP29: Expand & enhance the use of data to track and report progress

7. Overall Objectives Improve Linkage to Care Improve Engagement in Care
Improve ART Adherence
Improve Viral Load Suppression

8. Methods Involve Everyone Put our Public Health Hats on
Think in terms of Region and Community
Use Data
Identify Gaps in Care
Identify Interventions to fill Gaps
Use Quality Improvement Methodology
Share with Everyone

9. New York State Cascades9

10. New York State Cascade of HIV Care, 2016 Persons Residing in NYS† at End of 2016
93% of infected
74% of infected 80% of PLWDHI
Estimated infected is based on CDC’s June HIV Surveillance Supplemental Report vol. 21, No.4 reported that at the end of 2013 an estimated 13% of infected persons were unaware of their infection (ROS) as well as 5% unaware for persons residing in NYC.
CDC. Monitoring selected national HIV prevention and care objectives by using HIV surveillance data—United States and 6 U.S. dependent areas—2014. HIV Surveillance Supplemental Report 21(No.4).
65% of infected 70% of PLWDHI
87% of cases w/any care
†Based on most recent address, regardless of where diagnosed. Excludes persons with AIDS with no evidence of care for 5 years and persons with diagnosed HIV (non-AIDS) with no evidence of care for 8 years.
ǂ Estimated unknown 5.0% for NYC and 15% Rest of State
*Any VL, CD4, genotype test during the year.
BHAE/AI/NYSDOH

11. Cascade of HIV Care: Lower Hudson Ryan White Region Persons Residing in the Lower Hudson Ryan White Region† at End of 2016 (excludes prisoner cases)
85% of infected
65% of infected 77% of PLWDHI
59% of infected 70% of PLWDHI
90% of cases w/any care
†Based on most recent address, regardless of where diagnosed. Excludes persons with AIDS with no evidence of care for 5 years and persons with diagnosed HIV (non-AIDS) with no evidence of care for 8 years.
ǂ 15% were infected and unaware (CDC estimate)
* Any VL, CD4, genotype test during the year
BHAE/AI/NYSDOH

12. Cascade of HIV Care: Mid Hudson Ryan White Region Persons Residing in the Mid Hudson Ryan White Region† at End of 2016 (excludes prisoner cases)
85% of infected
62% of infected 73% of PLWDHI
55% of infected 64% of PLWDHI
88% of cases w/any care
†Based on most recent address, regardless of where diagnosed. Excludes persons with AIDS with no evidence of care for 5 years and persons with diagnosed HIV (non-AIDS) with no evidence of care for 8 years.
ǂ 15% were infected and unaware (CDC estimate)
* Any VL, CD4, genotype test during the year
BHAE/AI/NYSDOH

13. Introductions 13

14. Introduction Directions
Please share the following with the group:
Your name and title
Where you work
What is your favorite dessert?

15. Open Door Presentation15

16. CHCQLN 2017 VLS Quality Improvement Project Storyboard Template
Addressing the Individual
Karen Mandel

17. Improvement Project Background
Rationale
Viral load suppression is a key indicator of HIV healthcare. Although Open Door’s rate of VLS was high at the end of 2016 (91%), there is still room for improvement. While we work on population health, each individual matters as well.
Baseline Data
n = 120 active patients at the end of 2016
109 patients suppressed
91% VLS rate

18. -Ended 2016 with 11 patients unsuppressed

19. Improvement Project Goal
To increase the number of patients with suppressed viral loads from 91% to 95% in 2017
114 of 120 patients
5 more patients become suppressed
109 patients remain suppressed

20. Plan/Do Findings when 2016 process was reviewed
Barriers to VLS are not currently population- or system-based
Interventions need to address individual needs in a customized way
Change/improvement activity you selected
Original plan: Monthly case conference between CM and LCSW
However, staffing changed…
Revised plan July 12, 2017: Monthly case conference between CM and HIV Medial Specialist and up-to-date (12 months) medial chart review by “Master” HIV Medial Specialist
Measures
Process measures: Case conferences, medical chart review
Outcome measures: VL

21. Do/Study Mid-Course Data (Jan-June 2017)
n = 125 active patients at the end of June 2016
5 newly diagnosed
111 patients suppressed
89% VLS rate
-11 patients unsuppressed, and 3 more without labs

22. Do/Study
-What happened to the 11 patients who were unsuppressed at the end of 2016 by mid-year 2017?
-By mid course 2016, 1 had transferred out and 5 were suppressed, leaving 5 unsuppressed

23. Do/Study
-Added 7 more patients in the first 6 months of 2017 who were unsuppressed
-By the end of June we had 6 unsuppressed still
-Added to the 5 carried over from 2016 who remained unsuppressed, by the mid-year cascade we had 11 pts unsuppressed

24. Do/Study
-In addition to the 11 unsuppressed, we had 3 people with no VL measured during the 6 month period

25. Do/Study
And then we started our intervention in July
-5 from 2016 -

26. Do/Study
-Some pts had become suppressed so we had 5 left from 2016; 5 from the first 6 months of 2017; and 9 from the last 6 months of 2017
-Total of 19 individuals
Concisely describe what happened during your tests of change, using quantitative and qualitative data
Present data graphically (e.g. control chart, run chart, bar graph, line graph or other graphic representation). Add additional slides as needed.

27. Do/Study Results Data (Jan-Dec 2017)
n = 136 active patients at the end of 2017
123 patients suppressed
90% VLS rate
Ended 2017 with 13 patients unsuppressed
By January of them were already suppressed, 3 were individuals dx in the last quarter

28. Study Who is left unsuppressed? -8 pts
Describe your observations and further modifications of your tests of change

29. Study Baseline: 109/120 = 91% Goal: 114/120 = 95%
Mid-point: 111/125 = 89%
Year-end: 123/136 = 90%
We ended up where we started!

30. Study
Or did we?
18 individuals became suppressed in 2017

31. Act / Next Steps / Analysis
Maybe a goal of 95% suppression is too high!
Especially with individuals with a new dx being included in the rate
2018 goal of maintaining 90% overall VLS rate
Continue the individual focus to sustain gains
Case conferences bi-monthly (per feedback from the CMs)
Medical chart review every 12 months
Focus closely on the needs of the 8 individuals remaining unsuppressed from 2017
Apply individual focus to other QI initiatives
Nutrition and dental services
-What are your next steps based on the results of your quality improvement project?
Will you continue to test process changes using PDSA cycles?
How will you sustain gains?
How will you integrate into delivery care system?
How will you spread improvements to other service delivery areas?

32. Break 32

33. Reducing Stigma in HIV Care33

34. Measuring and Addressing Stigma in Healthcare Settings
Kelly Hancock
Program Assistant
NYSDOH AIDS Institute– Office of the Medical Director

35. What is HIV-related stigma?
HIV-related stigma is defined as “prejudice, discounting, discrediting, and discrimination directed at people perceived to have HIV.”
What is HIV-related stigma?
Internalized stigma: when one develops low self-esteem and negative feelings about themselves because of one’s HIV status3,4
Anticipated stigma: when one expects to be discriminated against in the future because of one’s HIV status3,4
Enacted stigma: when one experiences or has experienced discrimination, stereotyping, and/or prejudice as result of other people’s actions3,4
Intersectional stigma: when the stigma of being HIV+ is coupled with stigma related to other personal attributes such as gender, poverty, class, race, geography, migrant status, drug use, mental health diagnosis and sexuality or sexual orientation5
Earnshaw, Valeria A., and Chaudoior, Stephenie R “From Conceptualizing to Measuring HIV Stigma: A Review of HIV Stigma Mechanism Measures.” AIDS Behavior: 13(6):

36. Types of Stigma Internalized stigma (self)
“I feel ashamed of having HIV”
Anticipated stigma (fear of)
“If I go in for an appointment, healthcare workers will treat me with less respect”
Enacted stigma (discrimination)
“At my appointment, my doctor did not touch me without gloves on”
Types of Stigma
Internalized Stigma (Self-stigma)
Ones belief that they are “less than” others and are deserving of negative outcomes due to their HIV + status
Endorsing negative feelings and beliefs associated with HIV and applying to oneself
Internalized stigma—acceptance of one’s “lesser status”, manifesting in low self-esteem, sense of worth, self-blame, self-isolation/withdrawal
Anticipated Stigma
When one expects the stigmatizing behavior to occur – regardless of having this experience in the past
Ex. A HIV+ patient avoids going to the doctor because he/she believes that the doctor will act in stigmatizing ways
Experienced Stigma (Discrimination)
When one experiences stigmatizing behavior, past or present
Ex. HIV+ patient goes to doctor and doctor refuses to touch patient (any form of skin-on-skin contact)
Every level of stigma affects the patients health and well-being
Earnshaw, Valeria A., and Chaudoior, Stephenie R “From Conceptualizing to Measuring HIV Stigma: A Review of HIV Stigma Mechanism Measures.” AIDS Behavior: 13(6):

37. Patient Experience with Stigma in NYS
According to the Medical Monitoring Project (MMP), a population-based surveillance system that assesses clinical outcomes and behaviors of PLWH receiving care in the US between , in NYS (excluding NYC) and NYC:
MMP Statement
NYS (excluding NYC)
(N=421)
NYC
(N=1,577)
Perceived Stigma
“I hide my HIV status from others”
67%
47%
“It is difficult to tell people about my HIV infection”
74%
58%
Discrimination Experiences
Reported healthcare providers exhibited hostility or a lack of respect during a healthcare visit
26%
13%
Reported said discrimination occurred because of HIV infection
92%
69%
Source: NYSDOH Office of Public Health and NYC DOHMH HIV Epidemiology and Field Services Program

38. A framework for the effects of stigma on health (Earnshaw et al
A framework for the effects of stigma on health (Earnshaw et al., AIDS Behavior, 2013)

39. Negative Health Impacts of Stigma for PLWH

40. Why stigma reduction now?
Impacts of stigma lead to negative health outcomes
PLWH avoid getting care or disclosing status because of fears of discrimination
Source: NASTAD: HIV Prevention & Health Equity

41. Why is Stigma Hard to Change?
Goals by the end of the exercise
Participants will be able to identify….
Various factors promoting and restraining change in stigma
Possible interventions to change stigma and discrimination
Exercise
Why is Stigma Hard to Change?

42. 2016 New York State HIV Quality of Care Program Review
Measuring and Addressing Stigma in Healthcare Settings

43. Stigma Survey Origins
June 2015 – Quality of Care Clinical Advisory Committee (QAC)
Presentation from Laura Nyblade on work to develop a stigma measurement tool in healthcare settings
Early Stigma-Subcommittee first convened
Consisted of members of the Quality of Care Clinical Advisory Committee (QAC) and members of the Consumer Advisory Committee (CAC)

44. Stigma Survey for Healthcare Staff
Health Policy Project’s “Measuring HIV Stigma and Discrimination Among Health Facility Staff”
Background Information
Collecting demographics
Health facility environment and health facility policies
Questions on practices and experiences in the health facility
Questions on facility policy and work environment
Opinions about people living with HIV
Attitudes and willingness to care
Questions on key populations (not found in original tool)
Men Who Identify as Gay or Bisexual, People of Transgender and Gender Non-Conforming Experience, Women, People with a Mental Health Diagnosis, People of Color
Stigma Survey for Healthcare Staff

45. NYS HIV Quality of Care Program Review
Organizational Cascades
eHIVQUAL
HIV Tobacco Cessation Improvement Campaign
Measuring and Addressing Stigma in Healthcare Settings
July 2017
NYS HIV Quality of Care Program Review

46. Measuring and Addressing Stigma in Healthcare Settings
Three Components:
Administer the stigma survey to staff members
Solicit feedback from consumers
Create a stigma reduction action plan based off of results
Measuring and Addressing Stigma in Healthcare Settings

47. Stigma Staff Survey Findings/Themes
In general, survey respondents:
Have not received training on HIV-related stigma and discrimination
Did not have knowledge of policy against discrimination of key populations
Agreed that infection occurs due to irresponsible behavior
Observed people talking badly about:
Women
People of color
People with a mental health diagnosis
TG/GNC individuals
Have lack of training:
Women's health
People who use drugs
Stigma Staff Survey Findings/Themes

48. Stigma Reduction Action Plan Themes from across the state
Increasing staff education
LGBT health (STI screening), mental health, HIV-related stigma, SOGI
Welcoming, inclusive environment
Posters and resources for all populations, U=U
Creation of stigma reduction task forces (with both consumers and providers)
Creation of support groups for key populations
Stigma Reduction Action Plan Themes from across the state

53. Why is Stigma Hard to Change?
Thinking about the question…
Brainstorm Alone  Write single ideas/answers on a sticky note
Discuss ideas with your group
Organize the ideas into key themes
Why is Stigma Hard to Change?
& Page 12 of FRESH Workshop
It might be more engaging to do this as a full group
& ask 2 Steering Committee Members to work with you Jonathan at the end to sort & categorize the outputs (ideas) The process of sorting and categorizing is a QI process . . .that helps teams target interventions . . .

54. Lunch 54

55. Stigma Report Back 55

56. Stigma Reduction: Group Wrap-Up
Final thoughts about reducing stigma in Long Island?
What are we “missing” in terms of reducing stigma?
Stigma Reduction: Group Wrap-Up

57. Hudson Valley Health Advisory Surveillance Epidemiological Update

58. Hudson Valley Health Advisory
New diagnoses of HIV infection in residents of Dutchess, Orange, Putnam, Sullivan, and Ulster Counties have increased over 75% between 2015 and 2016.
Preliminary HIV data for 2017 continue to show an increase.
Primary & secondary syphilis increased 121% between 2015 and 2016.
Preliminary 2017 data show continued elevated numbers in this region.
Rates of HIV and STD coinfection are high in this area, with 32% of early syphilis cases residing in this area also having a diagnosis of HIV.
New diagnoses of HIV infection increased 75% between (2015: N=43; 2016: N=77) and 2017 HIV diagnosis data continue to show an increase in this area
It is important to keep in mind that while the number of new HIV diagnoses in the area has risen, persons may be diagnosed years after infection, so this does not necessarily mean that transmissions are increased or that transmissions are occurring from one person.
Increases in primary and secondary syphilis have also been noted in the area during the same time period.
Rates of HIV and STD co-infection are high, with 32% of the early syphilis cases also having a diagnosis of HIV

59. Chlamydia in the Hudson Valley Region, New York State
Age-Adjusted Rate: 
Chlamydia Cases per 100,000 Residents, 2016
Number of cases increasing since 2013 in this area
Cases clustered in higher population areas
Age adjusted rates higher than rest of statewide average in Westchester, and Sullivan
Highest burden among non-Hispanic blacks and Hispanics, and females <25
NYS excl NYC
New Infections by Year
Hudson Valley Region
In 2016, 68% of Chlamydia cases are diagnosed among females with >70% among year old's
The highest burden of Chlamydia is seen among black, NH females and Hispanic females.
Sources: NYSDOH Bureau of STD Prevention and Epidemiology
and 2014 Behavioral Risk Factor Surveillance System

60. Gonorrhea in the Hudson Valley Region, New York State
Age-Adjusted Rate: 
Gonorrhea Cases per 100,000 Residents, 2016
Number of cases increasing since 2014 in this area
Cases clustered in higher population areas
Age adjusted rates lower than rest of statewide average in all counties
Highest burden among non-Hispanic blacks, and males <30
In 2016, males accounted for 67% of gonorrhea cases
NYS excl NYC
New Infections by Year
Hudson Valley Region
The highest rate of infection is seen among males, years of age
Rates are highest among Black, NH males
Sources: NYSDOH Bureau of STD Prevention and Epidemiology
and 2014 Behavioral Risk Factor Surveillance System

61. Early Syphilis in the Hudson Valley Region, New York State
Age-Adjusted Rate: 
Early Syphilis Cases per 100,000 Residents, 2016
Early syphilis reflects infections within the past year. Primary and secondary syphilis, which will be discussed in future slides, reflect the most infectious stages of syphilis, and are infections within the past 6 months.
Number of cases increasing since 2014 in this area
Cases clustered in higher population areas
Age adjusted rates higher than rest of statewide average in Dutchess, Putnam, Westchester, and Sullivan
Highest burden among non-Hispanic blacks, and males <25-29
NYC excl NYC
New Infections by Year
Hudson Valley Region
90% of Early Syphilis cases are among men with 67% among men who have sex with men
The highest rate of infection is seen among males, years of age
Rates are highest among Black, NH males
Sources: NYSDOH Bureau of STD Prevention and Epidemiology
and 2014 Behavioral Risk Factor Surveillance System

62. Hudson Valley Region Partner Services Outcomes STD/HIV Index Cases, 2016
Disease
Reported Cases*
Assigned for
Investigation
Interviewed
Partners
Elicited 
Early Syphilis
254
240 (94)
209 (87)
186
HIV
164
142 (87)
104 (73) 72
Gonorrhea
1167
816 (70)
641 (79)
255
Chlamydia
7912
1763 (22)
1223 (69)
710
Individuals are assigned based upon prioritization
High proportion successfully interviewed
Aim to elicit at least one partner per individuals, which was not achieved likely due to competing demands of such a high number of chlamydia cases worked
*Messaged to Partner Services; for HIV, not synonymous with incidence or total new diagnoses
Sources: NYSDOH Bureau of STD Prevention and Epidemiology

63. = represents cases detected or averted due to PS intervention
Hudson Valley Region Partner Services Outcomes Partners to STD/HIV Cases, 2016
Disease
Assigned for
Investigation
Notified of Exposure
Examined
New
Infections* 
Preventive
Treatment
Early Syphilis
169
125 (67)
98 (78)
18 (18)
53 (54)
HIV 63
54 (75)
27 (50)
2 (7)
N/A
Gonorrhea
229
173 (68)
88 (51)
18 (20)
53 (60)
Chlamydia
652
414 (58)
220 (53)
96 (44)
104 (47)
2 new HIV infections were detected through Partner Services work
High proportion of early syphilis, gonorrhea, and chlamydia partners were either diagnosed and treated, or preventatively treated
= represents cases detected or averted due to PS intervention
*New Infections for HIV = New Positives
Sources: NYSDOH Bureau of STD Prevention and Epidemiology

64. Percent of new Early Syphilis1 Cases Tested for HIV within 30 days of syphilis diagnosis, 2015 and 20172, Upstate
38%
36%
There are opportunities for HIV testing among persons diagnosed with syphilis. This slide shows the HIV testing of HIV- early syphilis cases worked by Partner Services staff in NYS (outside of NYC).
1 Data restricted to persons not previously diagnosed with HIV, and investigated by Partner Services staff.
2 Data as of 1/19/ data are preliminary data are not shown because data collection processes changed in 2016 from paper field records to direct data entry; 2016 data are incomplete.

65. Chlamydia & Expedited Partner Therapy (EPT)
Chlamydia (Ct) is a common STD with ~100,000 cases reported in NYSⱡ in 2016
Single dose therapy of Azithromycin 1 gram orally; highly effective; no evidence of resistance
EPT is a way to decrease Chlamydia, one of the most commonly reported STDs
Partner Notification & Treatment Strategies: Provider Referral by PS staff, Self Referral by patient, and EPT
A clinician can provide medication or prescription to a patient, who brings it to his/her partner(s)*
Medication EPT (patient-delivered partner therapy)
Prescription EPT
ⱡ NYS Includes NYC
ⱡ EPT legal in NYS for Ct only *

66. Summary on final Hudson Valley Region data through 2016
The number of cases of chlamydia (CT), gonorrhea (GC), and early syphilis (ES) all increased from 2015 in this region.
2016 ES rates higher than in Rest of State (ROS) for 4 out of 7 counties. The ES rate in Dutchess County is almost double that of ROS.
Number of ES cases is increasing since at least 2000, and has doubled in the last four years (133 to 254).
Rates are highest among Black non-Hispanics males for GC and ES, and Black non-Hispanic and Hispanic females for CT.

67. Hudson Valley Health Advisory HIV Surveillance Epidemiological Update

68. Hudson Valley Space-Time Cluster
Dutchess, Orange, Putnam, Sullivan, and Ulster Counties
I am speaking to you today regarding a space-time cluster of new diagnoses occurring among residents of Dutchess, Orange, Putnam, Sullivan, and Ulster counties. I will refer to these counties as the Hudson Valley throughout this presentation.
AI/DEEP/BHAE

69. Background
Dutchess, Orange, Putnam, Sullivan, and Ulster counties (Hudson Valley/DUSOP area) space-time cluster
New diagnoses of HIV infection increased 75% between (2015: N=43; 2016: N=77)
2017 HIV diagnosis data continue to show an increase in this area
NB: While the number of new HIV diagnoses in the area has risen, persons may be diagnosed years after infection, so this does not necessarily mean that transmissions are increased or that transmissions are occurring from one person.
Increases in primary and secondary syphilis noted in the area
Rates of HIV and STI co-infection are high, with 32% of the early syphilis cases also having a diagnosis of HIV
New diagnoses of HIV infection increased 75% between (2015: N=43; 2016: N=77) and 2017 HIV diagnosis data continue to show an increase in this area
It is important to keep in mind that while the number of new HIV diagnoses in the area has risen, persons may be diagnosed years after infection, so this does not necessarily mean that transmissions are increased or that transmissions are occurring from one person.
Increases in primary and secondary syphilis have also been noted in the area during the same time period.
Rates of HIV and STD co-infection are high, with 32% of the early syphilis cases also having a diagnosis of HIV

70. Number of New Diagnoses
Persons Newly Diagnosed with HIV Infection by Residence at Diagnosis, *
Number of New Diagnoses
Year of HIV Diagnosis
This slide shows trends in new diagnoses for the Hudson Valley as a whole and for each county separately.
The Hudson Valley region is the grey line with squares; the counties are the lines below.
Between 2010 and 2016 the number of people newly diagnosed with HIV infection was declining, with a sharp increase in 2016.
Between 2015 and 2016, Orange County doubled its new diagnose (16 to 38) and Sullivan county saw its new diagnoses nearly double (12 to 22).
*Data as of September 2017

71. Persons Newly Diagnosed with HIV Infection by Hudson Valley and ROS, 2016*
Distribution by Race/Ethnicity
Distribution by Transmission Risk
Distribution by Age Group 1
Hudson Valley has similar race/ethnicity distributions as the ROS total.
Hudson Valley has a larger percentage of people with heterosexual transmission risk than ROS and an older age at diagnosis distribution, with nearly half of persons newly diagnosed age 45 and older compared o only 28% in Ra larger percentage of people diagnosed age 55+.
*Data as of September 2017
1Other race categories include Native American, Asian/Pacific Islander, Multi-Race
2History of Male-to-Male Sexual Contact
3History of Injection Drug Use

72. Comparison of Linkage to Care for New HIV Diagnoses, 2016*
These data highlight by region linkage to care among the newly diagnosed.
We use three basic measures to assess linkage to HIV medical care after diagnosis. Evidence of linkage is determined using reported laboratory test results. So whether a VL, CD4 or HIV nucleotide sequence (genotype) has been received by the NYSDOH.
Hudson Valley is performing above the NYS average overall for linkage to care within 30 days and slightly below the statewide average for entry to care in 90 days. 62% of persons newly diagnosed in the region receiving a genotype within 90 days of diagnosis is below the ROS average.
*Data as of September 2017
*Any VL, CD4, genotype test during the year

73. Comparison of HIV Care and Viral Suppression, 2016
Comparison of HIV Care and Viral Suppression, 2016* Persons Living with Diagnosed HIV Infection and Residing in NYS† at End of 2016
We can assess HIV care related measures for the prevalent population.
This slide shows the percentage of PLWDHI with evidence of any HIV related medical care within calendar year 2016 – again based on reported laboratory test results.
We also assess here the viral suppression status of all PLWDHI.
Viral suppression is defined as not detectable or <200 copies/ml using the at test closest to end-of-year.
We see that Hudson Valley performs worse than the state average on these measures, with only 64% of the persons living with HIV virally suppressed at the end of 2016.
Keep in mind the ETE 2020 goal of PLWDHI being virally suppressed is 85%, so there remains room for improvement here for both areas.
*Data as of September 2017
†Based on most recent address, regardless of where diagnosed. Excludes persons with AIDS with no evidence of care for 5 years and persons with diagnosed HIV (non-AIDS) with no evidence of care for 8 years.
**Any VL, CD4, genotype test during the year; ***At last test closest to the end of the year

74. Quick Overview: HIV Surveillance Procedures
Electronic laboratory reporting is the foundation of the HIV surveillance system
Laboratories and blood/tissue banks conducting HIV-related testing on NY residents and/or for NY clinicians (regardless of patient residence) are required to electronically report to the NYSDOH any laboratory test, tests or series of tests approved for the diagnosis of HIV or for the periodic monitoring of HIV infection with complete patient identifiers and address
Diagnostic and treating clinicians are mandated reporters
Matches to administrative data sources (e.g., STD lab reports, ADAP, AIRS, Medicaid, death reports, TB registry, etc.) augment these data
Surveillance Medical Record Review
Field staff conduct medical record review to collect information on suspected cases to confirm using CDC case reporting criteria
The NYS HIV surveillance system is robust and contains data from a variety of sources. The State maintains the whole state HIV surveillance registry, inclusive of NYC residents.
Electronic laboratory reporting is the foundation of the HIV surveillance system. Laboratories and blood/tissue banks conducting HIV-related testing on NY residents and/or for NY clinicians (regardless of patient residence) are required to electronically report to the NYSDOH any laboratory test, tests or series of tests approved for the diagnosis of HIV or for the periodic monitoring of HIV infection .
Diagnostic and treating clinicians are mandated reporters, via the Provider Report Form (PRF).
We also matches to a variety of administrative data sources, including STD lab reports, ADAP, AIRS, Medicaid, death reports, TB registry, for case ascertainment and to augment the surveillance data
Health department staff conduct medical record review to collect information on suspected cases to confirm using CDC case reporting criteria

75. Key HIV Surveillance Points
Increase in number of persons newly diagnosed with HIV infection in 2016
Dutchess, Orange, and Sullivan counties
Largest percentages of people newly diagnosed were
25-34 and 55+ years old at diagnosis
HIV Care Outcomes
Hudson Valley performs above the ROS average
Linkage to care within 30 days of HIV diagnosis
Hudson Valley performs below the ROS average
Entry to care in 90 days of HIV diagnosis
Receipt of HIV genotyping within 90 days of diagnosis
People living with diagnosed HIV infection receiving HIV care
People living with diagnosed HIV infection virally suppressed
Increase in number of persons newly diagnosed with HIV infection in 2016 were observed in Dutchess, Orange, and Sullivan counties
Largest percentages of people newly diagnosed were and 55+ years old at diagnosis
Hudson Valley performs above the ROS average
linkage to care within 30 days of HIV diagnosis
Hudson Valley performs below the ROS average
Entry to care in 90 days of HIV diagnosis
People living with diagnosed HIV infection receiving HIV care
People living with diagnosed HIV infection virally suppressed

76. Syphilis is increasing in these counties
Health alert: Key STI surveillance trends in DUSOP*
Primary and secondary (P&S)** syphilis cases in these select counties increased 121% from 2015 to 2016 to 53 cases [statewide (including NYC) increase was 22%]
Preliminary rest of state (ROS) ± data for these counties show similar trend continuing through 2017 (138% percent increase from ) (ROS± total increase was 7% for the same time period)
Syphilis is increasing in these counties
Gonorrhea, and chlamydia cases in these select counties increased 5%, and 9% respectively from 2015 to 2016 [statewide (including NYC) increases were 13%, and 6%, respectively]
Preliminary ROS± data for these counties show similar trend continuing through 2017 (50%, and 12% increase for gonorrhea and chlamydia, respectively, from ) (ROS± total increase was 20%, and 9% for gonorrhea and chlamydia, respectively, for the same time period)
Gonorrhea and chlamydia also increasing
About 32% of the early syphilis cases in these counties also had a diagnosis of HIV
Rates of HIV and STD co-infection high
*2017 data is considered preliminary
**The most infectious stages of syphilis; early syphilis includes infections within the past 12 months
± 2017 New York City data not yet available

77. NYSDOH, Health Care and Community Partner Efforts
NYSDOH reaching out to LHD, health care, and community partners
Health Care Providers should:
Offer and perform HIV and STI diagnostic testing
Treat promptly or link patients immediately to care and treatment
Ensure prognostic testing, including HIV viral load, CD4 and genotype, is ordered
Assess sexual risk and drug use for every patient
Offer Pre-Exposure Prophylaxis (PrEP) and Post-Exposure Prophylaxis (PEP)
Community Based Organizations should:
Assess sexual risk and drug use for program participants/clients
Implement targeted client recruitment
Offer testing for HIV and STIs for individuals at high risk
Provide harm reduction services
Offer linkage and navigation services
Engage in condom promotion, education, and distribution
• Assess risk: conduct a comprehensive behavioral sexual risk assessment for program participants/clients. Ask about specific behaviors, such as the number of partners, type of sex (i.e., vaginal, anal, oral), sex of partners, drugs used and route of drug ingestion to help guide laboratory testing.
• Implement targeted client recruitment: target agency services to identify high risk individuals who do not access health care services or who may not otherwise have access to HIV testing in clinical settings—these persons may benefit most from HIV testing services in nonclinical settings.
• Offer testing for HIV and STDs for individuals at high risk: conduct venue based and/or mobile testing activities to key priority populations including MSM regardless of race, young men who have sex with men (YMSM) of color, African American women, sex and needle sharing partners of HIV positive individuals, persons presenting with evidence of active injection or other drug use, persons diagnosed with STDs, sex or needle sharing partners of persons diagnosed with STDs.
• Provide harm reduction services: facilitate access to clean syringes and essential support services for drug users.
• Offer linkage and navigation (L&N) services: assist HIV positive or high risk negative individuals to obtain timely, essential and appropriate medical, prevention and support services to optimize his or her health and prevent HIV/STD/HCV transmission and acquisition.
• Provide effective behavioral interventions: implement prevention activities that have been shown to be successful by evaluation research.
• Engage in condom promotion, education, and distribution:

78. New York State Clinician Reporting and HIV/AIDS Provider Portal
We wanted to take a few minutes to remind clinicians and heath care providers how to report and how to request from the Health Department information on their patients who are thought to be out of care and in need of linkage services.
The mechanism for both is the New York State Clinician Reporting and HIV/AIDS Provider Portal

79. Clinician Reporting Requirements
Public Health Law, Article 21, Title III requires clinicians to report by name
Initial or previously unreported diagnoses of HIV infection
HIV illness – new to the practice or returning to care after extended time
Initial or previously unreported AIDS diagnoses
If available, contacts of persons with HIV or AIDS
Protocol exists for identification and screening of victims of domestic violence
Requirement is to report within 14 days of diagnosis
Reporting via the Medical Provider HIV/AIDS and Partner/Contact Report Form (DOH-4189)
Public Health law requires medical providers report cases of HIV infection and AIDS to the New York State Department of Health (NYSDOH) using the DOH-4189 Medical Provider HIV/AIDS and Partner/Contact Report Form (PRF).
Completion of the PRF within 14 days of diagnosis.
The PRF is now able to be completed electronically using the Provider Portal on the NYSDOH Health Commerce System.
Access to the HIV/AIDS Provider Portal is available to NYS licensed MD, DO, DDS, NP, PA and midwife clinicians with a valid medical license number associated with their HCS profile. Once the licensed clinician establishes her/his account, she/he is able to designate the HIV/AIDS Provider Portal usage to a delegate.

80. Three Key Purposes of the Medical Provider and Partner/Contact Report Form
Important source of data for confirming HIV case surveillance eligibility and documenting risk of infection
Data are used nationally to determine the allocation of prevention and care funding to states and localities
Key source of variables used in the CDC methodology to estimate HIV incidence
Particularly testing history and treatment information
Important link of patients to Health Department partner services and a key source of named partners/contacts
Important source of data for confirming HIV case surveillance eligibility and documenting risk of infection.
Data are used nationally to determine the allocation of prevention and care funding to states and localities
Key source of variables used in the CDC methodology to estimate HIV incidence. Particularly testing history and treatment information.
Important link of patients to Health Department partner services and a key source of named partners/contacts
Finally, the PRF is often the only indication the NYSDOH receives of a patient new to New York, but not newly diagnosed, and perhaps not in need of extensive Health Department Partner Services. Additionally, particularly for the well suppressed patient who moves into NYS, the report by the clinician can be the only indication that the person is in fact HIV positive.
NYSDOH/AI/BHAE

81. HIV/AIDS Provider Portal

82. HIV/AIDS Provider Portal
Launched in 2016 to help clinicians:
Meet their reporting requirements electronically
To request information for their patients who are thought to be in need of assistance with linkage to or retention in HIV medical care.
Secure NYSDOH HCS infrastructure with layers of security
The HIV/AIDS Provider Portal was launched in 2016 to help clinicians:
Meet their reporting requirements electronically, and
To request information for their patients who are thought to be in need of assistance with linkage to or retention in HIV medical care.
The HIV/AIDS Provider Portal is house on the secure NYSDOH Health Commerce System infrastructure and is protected by a variety of layers of security.

83. HIV/AIDS Provider Portal: two key functions
Meet their reporting requirements electronically
Request information on their patients who are thought to be out of HIV medical care
The Portal has two key functions:
Clinicians or their designees can submit PRF forms electronically
This is the mechanism for clinicians or their designees to request information on their patients who are thought to be out of HIV medical care

84. Bureau of HIV/AIDS Epidemiology AIDS Institute, NYSDOH
Empire State Plaza
Albany New York 12237
The Bureau of HIV/AIDS Epidemiology is available to assist clinicians with accessing the portal. We can be reached at or via
Requests for aggregate HIV surveillance data or reports can be sent to

85. Consumer Involvement 85

86. AIDS Institute Quality of Care Program
Standards for Consumer Involvement in Quality Improvement
Consumer(s):
Are routinely asked to provide input/feedback in the selection of quality improvement (QI) priorities
Participate in HIV quality management (QM) program activities, as members of the QM committee
Provide feedback on the HIV QM program by responding to formal solicitations for public comment and by participating in an organization’s consumer advisory board.
Are offered opportunities to participate in trainings in QI and are provided with an organization’s performance data results and findings. 
Experience is assessed at least annually and findings are formally integrated into QI activities and communicated back to staff and consumers, as specified in the guidance issued by the AIDS Institute

87. Organizational Assessment
Completed by coaches to assess Quality of Care Program Infrastructure
Organization that score below a 3 on consumer involvement section trigger coaching and TA

88. Quality of Care 2018 Cascade Guidance88

89. Please refer to guidance which was distributed on 3/1/18

90. QI Training for 2018 90

91. What’s Coming up? October 26 Mid and Lower Hudson Regional Group
November 2, Central NY Regional Group w/HIV Care Network
November 15 Long Island Regional Group w/ETE
December 6, Bronx Regional Group w/DSRIP
December 19, Lower Manhattan Regional Group
December 20, Northeastern NY Regional Group

92. Contact Information
Steve Sawicki, NYLinks Lead,
Regional Leads
Upper Manhattan—Susan Weigl & Jonathan Gomez,
Lower Manhattan—Susan Weigl & Jonathan Gomez
Western NY—Nanette Brey Magnani,
Long Island—Steven Sawicki
Central NY & Southern Tier—Laura O’Shea,
Mid & Lower Hudson—Steve Sawicki
Queens—Nova West,
Brooklyn—Clemens Steinbock, & Zeenath Rehana
Bronx—Dan Belanger,
Northeastern NY—Steve Sawicki
Staten Island—Steve Sawicki
If not sure,