SUBJECT
Title
AUTHORIZE ACCEPTANCE OF HIV/AIDS SERVICES GRANT FUNDING AND AUTHORIZE HIV/AIDS SERVICES PROCUREMENTS (DISTRICTS: ALL)
Body
OVERVIEW
For 31 years the San Diego County Board of Supervisors (Board) has authorized grants and agreements with the U.S. Health Resources and Services Administration (HRSA) to provide care and treatment services to persons living with HIV. These funding sources include the Ryan White HIV/AIDS Treatment Extension Act of 2009 (RWTEA) Part A and the RWTEA Part A Minority AIDS Initiative (MAI). The RWTEA Part A and RWTEA Part A MAI comprise the single largest federal funding source for HIV services received by the County of San Diego (County). The County received notification of a grant award on May 27, 2022. The RWTEA Part A funding is $11,183,176, and the RWTEA Part A MAI funding is $793,221, for a total of $11,976,397 for the period of March 1, 2022 through February 28, 2023.
HIV/AIDS services are delivered via competitively procured contracts with community-based providers, and include outpatient ambulatory health, oral health, psychiatry, medical and non-medical case management, mental health, early intervention, outpatient substance use treatment, focused services for persons of color, food and transportation, rental subsidy assistance and emergency housing assistance, and emergency financial assistance. These contracted services are funded by RWTEA Part A and RWTEA Part A MAI, as well as RWTEA Part B which is funded by HRSA and administered through California Department of Public Health. Today’s action seeks the Board to approve acceptance of the RWTEA Part A and RWTEA Part A MAI funding. Additionally, today’s action also requests the Board to authorize the Director, Department of Purchasing and Contracting to issue Competitive Solicitations for HIV/AIDS services. Lastly, today’s action would authorize the application for any additional funds to be used to address testing, prevention and care, and treatment needs of individuals and families in San Diego County who are impacted by HIV, sexually transmitted diseases, and viral hepatitis.
This item supports the County’s Getting to Zero initiative by funding services that help people living with HIV remain in care and achieve viral suppression. Research has demonstrated that persons who have achieved viral suppression are not able to transmit HIV to others sexually. In addition, this item supports the County’s vision of a just, sustainable, and resilient future for all, specifically those communities and populations in San Diego County that have been historically left behind, as well as our ongoing commitment to the regional Live Well San Diego vision of healthy, safe, and thriving communities. This will be accomplished by building better health through providing access to high quality care and treatment services for HIV, sexually transmitted disease, and viral hepatitis, leading to improved physical and behavioral health which promotes a healthy, safe, and thriving region.
RECOMMENDATION(S)
CHIEF ADMINISTRATIVE OFFICER
1. Waive Board Policy B-29, Fees, Grants, Revenue Contracts - Department Responsibility for Cost Recovery, which requires prior approval of revenue agreement applications and full-cost recovery of grants.
2. Authorize the acceptance of $11,183,176 and $793,221 in grant funds from the Health Resources and Services Administration for the period of March 1, 2022 through February 28, 2023, for Ryan White Part A and Part A Minority AIDS Initiative respectively, and authorize the Clerk of the Board to execute all required grant documents, upon receipt, including any annual extensions, amendments and/or revisions thereto that do not materially impact or alter the services or funding level.
3. In accordance with Section 401, Article XXIII of the County Administrative Code, authorize the Director, Department of Purchasing and Contracting, to issue Competitive Solicitations for the service categories listed below, and upon successful negotiations and determination of a fair and reasonable price, award contracts for a term of one year and four option years, and up to an additional six months if needed, pending availability of funds, and to amend the contracts as needed to reflect changes to services and funding, subject to the approval of the Agency Director, Health and Human Services Agency.
a. Medical Case Management
b. Non-Medical Case Management
c. Non-Medical Case Management for Housing
d. Mental Health
e. Early Intervention Services
f. Substance Use Treatment: Outpatient
g. Focused Services for Persons of Color, including multi-disciplinary terms and targeted client advocacy
h. Food Services: Food Bank/Home-Delivered Meals/Medical Nutrition Therapy
i. Transportation
j. Housing: Partial Assistance Rental Subsidy
k. Housing: Emergency Housing Assistance
l. Emergency Financial Assistance
4. Authorize the Agency Director, Health and Human Services Agency, to apply for any additional funding opportunity announcements, if available, to address the prevention, testing, care, and treatment needs of those impacted by HIV/AIDS, other sexually transmitted diseases, and viral hepatitis.
EQUITY IMPACT STATEMENT
Since the beginning of the epidemic, HIV has disproportionately impacted our most vulnerable residents. Gay, bisexual, and other men who have sex with men, for instance, are currently estimated to comprise less than 2% of the adult population, and yet they comprise 62% of recent HIV diagnoses and 71% of persons living with HIV. Moreover, in San Diego County, like much of the rest of the United States, HIV has disproportionately impacted Black and Hispanic communities. Blacks comprise less than 5% of the county’s population but comprise 12% of recent HIV diagnoses. Hispanics comprise 34% of the population of the county yet comprise 48% of recent HIV diagnoses.
Since its inception in 1990, the Ryan White HIV/AIDS Treatment Extension Act (formerly the Ryan White CARE Act) has focused on ensuring access to treatment and support services for the most vulnerable residents. Thus far during the last grant period (March 1, 2021- February 28, 2022), a total of 3,313 clients received services funded by Ryan White Part A in San Diego County. Of those clients, 54% (1,786) were Hispanic and 13% (423) were Black.
The success in reaching our residents and communities most disproportionately impacted by HIV is due in large part to the HIV Planning Group, an official advisory board to the San Diego County Board of Supervisors that also has the legislative authority to allocate Ryan White Part A funding to respond to local needs as determined by review of epidemiologic data and extensive engagement of our communities. In partnership with the HIV Planning Group, the County of San Diego Health and Human Services Agency (HHSA) conducts needs assessments every three years among persons living with or those vulnerable to HIV, assessments of system capacity and capabilities every three years, and focus groups with different communities annually. During Fiscal Years 2019-20 and 2020-21, the HIV Planning Group engaged a consultant to conduct a community engagement process to identify how policy, planning, and funding changes could further close the disproportionalities we see among Black, Hispanic, and Transgender communities. The HIV Planning Group and HHSA are currently implementing the recommendations from the final report.
FISCAL IMPACT
Funds for this request are included in the Fiscal Year 2022-24 Operational Plan in the Health and Human Services Agency. If approved, this request will result in estimated costs of $12,116,451 and revenue of $11,976,397 in Fiscal Year 2022-23 for the term of these grants. The funding sources are Ryan White Part A and Part A Minority AIDS Initiative from the U.S. Health Resources and Services Administration. A waiver of Board Policy B-29 is requested because the funding does not offset all costs. These costs are estimated at $140,054 for the term of this grant. The funding source for these costs will be existing Health Realignment allocated for these programs. The public benefit for providing these services far outweighs these costs. There will be no change in net General Fund costs and no additional staff years.
BUSINESS IMPACT STATEMENT
N/A
Details
ADVISORY BOARD STATEMENT
The HIV Planning Group reviewed recommendations 1, 2, and 4, and recommended approval of the recommendations on June 22, 2022.
The Health Services Advisory Board reviewed this item on August 2, 2022, and recommended approval of the recommendations.
BACKGROUND
On March 1, 2016 (25), the San Diego County Board of Supervisors (Board) adopted the Getting to Zero initiative, which seeks to end the HIV epidemic by 2026. Since its adoption, the Getting to Zero initiative has evolved into a comprehensive approach to ending the HIV epidemic, with five core strategies:
1. Test: Link everyone living with HIV in San Diego County to HIV treatment and other services, such as medical case management and mental health services, that provide support for remaining in treatment.
2. Treat: Ensure that everyone living with HIV in San Diego County has access to HIV treatment services so that persons living with HIV can achieve viral suppression.
3. Prevent: Identify everyone at risk for HIV infection in San Diego County and link them to HIV prevention resources, such as pre-exposure prophylaxis, that provides support for remaining HIV-negative.
4. Engage: Continue partnering with communities disproportionately impacted by HIV to achieve collective impact and improve outcomes along the HIV care continuum.
5. Improve: Engage in continuous quality improvement activities to achieve the objectives of the Getting to Zero plan.
According to the most recent data available, as of December 31, 2020, an estimated 14,237 people were living with HIV in San Diego County. In 2020, there were 302 newly diagnosed HIV cases in San Diego County, which is a decrease of 39.8% from the 502 diagnosed cases in 2016 when Getting to Zero was launched. Despite the reduction, HIV continues to be a major public health concern in San Diego County, with an average of one new HIV diagnosis every day.
The County of San Diego (County) has received Ryan White Part A funds since 1991. Services funded by Ryan White Treatment Extension Act (RWTEA) Part A and RWTEA Part A Minority AIDS Initiative (MAI) revenue play a vital role in the County’s Getting to Zero initiative. RWTEA Part A services fill gaps in the local HIV service delivery system by ensuring individuals living with HIV have access to high quality HIV primary care and additional support services without regard to their ability to pay, their insurance status, or their immigration status. Moreover, RWTEA is deemed the “payer of last resort,” meaning that it can only pay for services when no other payer exists, or all other payer sources have been exhausted. This requirement ensures that funding is preserved for clients who would otherwise not have access to services. Funded service categories include HIV primary medical and dental care, case management, emergency and temporary housing assistance, mental health services, substance use disorder treatment services, emergency financial assistance, and other supportive services. Currently, in San Diego County, over 3,700 persons living with HIV receive at least one of these services funded by RWTEA Part A each year.
The goal of the RWTEA is to ensure all people living with HIV are linked to and are retained in HIV primary medical care. The key measure of success is the rate of viral suppression. A person living with HIV who is not virally suppressed would expect to have 50,000 or more copies of HIV in a milliliter of blood. However, when treated, the number can drop below 200, at which point the virus is deemed “suppressed.” When that happens, HIV can no longer do any further damage to the immune system. When a person living with HIV has been virally suppressed for six months or longer, they cannot transmit HIV sexually to anyone else. In calendar year 2020, 59% of people living with diagnosed HIV achieved viral suppression in San Diego County. Patients in the RWTEA Part A system of care have even better rates of viral suppression. In calendar year 2021, patients receiving RWTEA Part A services in San Diego County, who had a recorded viral load test, showed a suppression rate of 91%, (2,539 of 2,788). Additional data from U.S. Department of Health and Human Services Health Resources and Services Administration (HRSA), which oversees the Ryan White program, shows that in 2020 San Diego County had one of the highest viral suppression rates of the 52 jurisdictions funded in the United States and Puerto Rico.
RWTEA Part A MAI was established in 1999 to improve access to HIV care and health outcomes for persons of color. In addition to services funded by RWTEA Part A, services funded by RWTEA Part A MAI include outreach, medical case management, non-medical case management, mental health counseling, outpatient substance use disorder treatment, and medical transportation services. In calendar year 2021, there were 278 clients served in Part A MAI. Of those, 90% were virally suppressed (226 of 250 with a viral load test on file).
On October 6, 2021, the County Health and Human Services Agency submitted the annual RWTEA Part A funding application to HRSA. On May 27, 2022, HRSA notified the County of an award of $11,976,397 for the term of March 1, 2022 through February 28, 2023. Funding awarded includes $11,183,176 in RWTEA Part A revenue, and $793,221 in RWTEA Part A MAI revenue. In comparison to the previous grant year, funding for RWTEA Part A and funding for RWTEA Part A MAI were at the same funding level. The RWTEA Part A funding formula is based on the number of people living with HIV within the jurisdiction and the competitiveness of the County’s annual application for funding. The RWTEA Part A MAI funding formula is based on the number of persons of color living with HIV within the jurisdiction.
A waiver of Board Policy B-29 is requested because the funding does not offset all costs. Unrecovered costs are estimated at $140,054 for Fiscal Year 2022-23. The funding source for these unrecovered costs will be existing Health Realignment allocated for these programs. The public benefit for providing these services far outweighs these costs. RWTEA Part A fills an important gap in the local HIV service delivery system by ensuring individuals with HIV have access to, and are retained in, high quality HIV primary care to achieve viral suppression. These aspects are keys to advancing the Getting to Zero initiative, which is an overwhelming benefit to the public.
HIV/AIDS services are delivered via competitively procured contracts with community-based providers, and include outpatient ambulatory health, oral health, psychiatry, medical and non-medical case management, mental health, early intervention, outpatient substance use treatment, focused services for persons of color, food and transportation, rental subsidy assistance and emergency housing assistance, and emergency financial assistance. These contracted services are funded by RWTEA Part A and RWTEA Part A MAI, as well as RWTEA Part B.
Today’s action seeks authorization to accept $11,183,176 in RWTEA Part A funding and $793,221 in RWTEA Part A MAI funding from HRSA for the period of March 1, 2022, through February 28, 2023, and to authorize the Clerk of the Board to execute all required grant documents, upon receipt. Additionally, today’s action also requests the Board to authorize the Director, Department of Purchasing and Contracting to issue Competitive Solicitations for HIV/AIDS services. Lastly, today’s action requests the Board to authorize the Agency Director, Health and Human Services Agency to apply for any additional funding opportunity announcements, if available, to address the prevention, testing, care and treatment needs of those impacted by HIV/AIDS and other sexually transmitted diseases.
LINKAGE TO THE COUNTY OF SAN DIEGO STRATEGIC PLAN
Today’s proposed action supports the Equity (Health) and Community (Quality of Life) initiatives in the County of San Diego’s 2022-2027 Strategic Plan as well as the regional Live Well San Diego vision by improving access to high-quality and efficient medical care and support services that contribute to improved physical and behavioral health.
Respectfully submitted,
HELEN N. ROBBINS-MEYER
Chief Administrative Officer
ATTACHMENT(S)
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