1. 1 Overview of Ryan White-Funded Rapid Testing Services Benjamin Tsoi, MD, MPH Director, HIV Testing Unit Mara Pillinger, MPH Technical Assistance Coordinator, HIV Testing Unit

2. Ryan White-Funded Testing Ryan White (Ryan White) provides testing under: Ryan White (Ryan White) provides testing under: BASE-funded EIS contracts BASE-funded EIS contracts MAI-funded ESC contracts MAI-funded ESC contracts Harm reduction (HRR) contracts Harm reduction (HRR) contracts Core services: Core services: Rapid HIV Testing (RHT) Rapid HIV Testing (RHT) Confirmatory Testing * Confirmatory Testing * Linkage to Care (LtC) ** Linkage to Care (LtC) ** *As of Mar ‘10 for HRR & Aug ‘10 for EIS/ESC **As of Mar ’10 for HRR

3. Ryan White Testing Contracts 35 contracts funding 31 agencies across 5 boroughs 35 contracts funding 31 agencies across 5 boroughs Diverse settings Diverse settings Community-based organizations (CBOs) Community-based organizations (CBOs) Hospitals Hospitals Community health centers (CHCs) Community health centers (CHCs)

4. Ryan White Testing Contracts Diverse Settings CBOs target CBOs target MSM (& MSM of color), African Americans, Latinos, immigrants, the homeless, formerly incarcerated, current/former substance users, etc. MSM (& MSM of color), African Americans, Latinos, immigrants, the homeless, formerly incarcerated, current/former substance users, etc. Hospitals offer testing in ERs, inpatient units (e.g. internal medicine, psych, detox) & outpatient clinics (e.g. STDs, OB/GYN) Hospitals offer testing in ERs, inpatient units (e.g. internal medicine, psych, detox) & outpatient clinics (e.g. STDs, OB/GYN)

5. Testing Program Goals Identify PLWHA through testing and link them to medical care Identify PLWHA through testing and link them to medical care Provide RHT in communities with high prevalence of HIV Provide RHT in communities with high prevalence of HIV Targeted outreach to at-risk populations and those with a high proportions of delayed/concurrent diagnosis Targeted outreach to at-risk populations and those with a high proportions of delayed/concurrent diagnosis Routinized testing in medical settings in high prevalence neighborhoods Routinized testing in medical settings in high prevalence neighborhoods Provide LtC for newly-diagnosed persons or those who have been out-of-care for >9 months or have never before been in care in NYC Provide LtC for newly-diagnosed persons or those who have been out-of-care for >9 months or have never before been in care in NYC Serve as payer of last resort Serve as payer of last resort

6. Ryan White Testing Contract Distribution CBOsHospitals/CHCsTotalsBronx527 Brooklyn437 Manhattan11718 Queens202 Staten Island 101 Totals231235 NB: This chart reflects the number of funded agencies with headquarters in each borough. Many agencies test across multiple boroughs.

7. Ryan White Testing Models Targeted Testing Targeted Testing Outreach-based—identifying those at high- risk Outreach-based—identifying those at high- risk CBOs & Hospitals/CHCs CBOs & Hospitals/CHCs Routinized testing Routinized testing Screening—routine offer of an HIV test to every patient who sees presents to a clinical setting Screening—routine offer of an HIV test to every patient who sees presents to a clinical setting Hospitals/CHCs Hospitals/CHCs Mandated by new NYS HIV Testing Law Mandated by new NYS HIV Testing Law

8. Ryan White Testing Funding Total funding= ~$ 6.5 million/year Total funding= ~$ 6.5 million/year BASE=~$3.8 million/year BASE=~$3.8 million/year MAI=~$1 million/year MAI=~$1 million/year HRR= ~ $1.7 million/year HRR= ~ $1.7 million/year

9. Ryan White Testing Data (Jan 2008-Oct 2010) Over 167,000 tests conducted Over 167,000 tests conducted 30% increase in volume of tests between 2008 and 2009; on track to meet/exceed 2009 performance in 2010 30% increase in volume of tests between 2008 and 2009; on track to meet/exceed 2009 performance in 2010 ~ 2,400 preliminary positives identified ~ 2,400 preliminary positives identified ~350 clients linked to care ~350 clients linked to care 63% of self-reported “new positives” were linked 63% of self-reported “new positives” were linked Over 1,000 out-of-care previously diagnosed positives were linked to care Over 1,000 out-of-care previously diagnosed positives were linked to care

10. Ryan White Testing Data (July 2009-June 2010) EIS/ ESC HRRTotal # tested 52,89313,88866,781 % preliminary seroprevalence 1.2%(n=625)1.6%(n=224)1.3%(n=849) % confirmed 50%(n=310)20%(n=44)42%(n=342) % linked to care 49%(n=151)5%(n=2)43%(n=153) # known +s linked to care 377N/A377

11. 11 HIV Testing In NYC A Complicated Picture

12. HIV Testing in NYC A Complicated Picture Testing Providers

13. Clinical Settings Clinical Settings Hospitals Hospitals CHCs CHCs STD Clinics STD Clinics TB Clinics TB Clinics Dental Clinics Dental Clinics Testing Providers HIV Testing in NYC A Complicated Picture

14. Clinical Settings Clinical Settings CBOs CBOs Agency- based Agency- based Mobile Testing Mobile Testing Testing Events (fairs, etc.) Testing Events (fairs, etc.) Testing Providers HIV Testing in NYC A Complicated Picture

15. Clinical Settings Clinical Settings CBOs CBOs Correctional Settings Correctional Settings Testing Providers HIV Testing in NYC A Complicated Picture

16. Clinical Settings Clinical Settings CBOs CBOs Correctional Settings Correctional Settings Private Practices Private Practices Testing Providers HIV Testing in NYC A Complicated Picture

17. Clinical Settings Clinical Settings CBOs CBOs Correctional Settings Correctional Settings Private Practices Private Practices Testing Providers Testing Payers HIV Testing in NYC A Complicated Picture

18. Clinical Settings Clinical Settings CBOs CBOs Correctional Settings Correctional Settings Private Practices Private Practices Direct Funders Direct Funders CDC CDC SAMHSA SAMHSA NYS DOH NYS DOH HRSA (RW Part C) HRSA (RW Part C) Testing Providers Testing Payers HIV Testing in NYC A Complicated Picture

19. Clinical Settings Clinical Settings CBOs CBOs Correctional Settings Correctional Settings Private Practices Private Practices Direct Funders Direct Funders Third Party Payers Third Party Payers Testing Providers Testing Payers HIV Testing in NYC A Complicated Picture

20. Clinical Settings Clinical Settings CBOs CBOs Correctional Settings Correctional Settings Private Practices Private Practices Direct Funders Direct Funders Third Party Payers Third Party Payers NYC DOHMH NYC DOHMH Testing Providers Testing Payers HIV Testing in NYC A Complicated Picture

21. HIV Testing Funded by NYC DOHMH STD Clinics STD Clinics TB Clinics TB Clinics NYC Jails NYC Jails Bureau of HIV/AIDS Bureau of HIV/AIDS Ryan White funds Ryan White funds CDC funds CDC funds City Tax Levy Funds City Tax Levy Funds

22. HIV Testing Funded by NYC DOHMH STD Clinics STD Clinics TB Clinics TB Clinics NYC Jails NYC Jails Bureau of HIV/AIDS Bureau of HIV/AIDS Ryan White portfolio Ryan White portfolio Prevention portfolio Prevention portfolio

23. Prevention Testing Portfolio Prevention is the other major portfolio of DOHMH testing contracts Prevention is the other major portfolio of DOHMH testing contracts Funded by CDC & City Tax Levy dollars Funded by CDC & City Tax Levy dollars 39 contracts in 32 agencies 39 contracts in 32 agencies Testing models: Testing models: Screening Screening Targeted Testing Targeted Testing Social Network Strategy Social Network Strategy Bath houses, homeless shelters, etc. Bath houses, homeless shelters, etc.

24. Comparing Contract Distribution BoroughCBOsHospitals/CHCsTotal RWPrevRWPrevRWPrev Bronx532477 Brooklyn423577 Manhattan11107131823 Queens200222 Staten Island 100010 Total231512243539

25. Comparing Funding Distribution *Post Aug 2010 Ryan White * PreventionCBOs ~$4.2 million ~$1.3 mill Hospitals/ CHCs ~$1.8 million ~$4.5 mill

26. A Unified Testing Effort? 9 separate contract families result in significant overlap 9 separate contract families result in significant overlap Overlap in targeted populations (risk groups) Overlap in targeted populations (risk groups) Agencies targeting same populations in same neighborhoods creates “competition” Agencies targeting same populations in same neighborhoods creates “competition” Overlap in funded agencies Overlap in funded agencies Roughly 1/3 of funded agencies have >1 contract Roughly 1/3 of funded agencies have >1 contract Agencies use different contracts to fund the same activities at different times Agencies use different contracts to fund the same activities at different times Creates greater administrative and reporting burden for agencies Creates greater administrative and reporting burden for agencies

27. A Unified Testing Effort? Different contract structures with different payment points and different reimbursement rates fuels differences in performance Different contract structures with different payment points and different reimbursement rates fuels differences in performance Before mid-2010 Before mid-2010 Prevention paid for testing, confirmation & linkage Prevention paid for testing, confirmation & linkage EIS/ESC paid for testing & linkage EIS/ESC paid for testing & linkage HRR paid for testing HRR paid for testing Only EIS/ESC paid for linkage of “known positives” Only EIS/ESC paid for linkage of “known positives”

28. One City, One Plan Propose a joint RFP for Ryan White- & Prevention-funded contracts Propose a joint RFP for Ryan White- & Prevention-funded contracts Advantages: Advantages: Enables Planning Council to support one unified testing plan for the entire city Enables Planning Council to support one unified testing plan for the entire city Allows agencies to submit only one application Allows agencies to submit only one application Enables agencies to plan, propose & manage a single comprehensive testing program Enables agencies to plan, propose & manage a single comprehensive testing program Reduces administrative burden and reporting burden for agencies Reduces administrative burden and reporting burden for agencies Provides consistent reimbursement structure Provides consistent reimbursement structure

29. One City, One Plan Advantages, con’t: Advantages, con’t: Enables DOHMH to better coordinate funding, ensuring that all target groups and all areas of the city are covered by both CBOs & hospitals/CHCs Enables DOHMH to better coordinate funding, ensuring that all target groups and all areas of the city are covered by both CBOs & hospitals/CHCs Reduces administrative burden for DOHMH Reduces administrative burden for DOHMH