Ryan White Part A & Minority AIDS Initiative Service Utilization in the Indianapolis Transitional Grant Area: FY 2015 July 7, 2016 Tammie L. Nelson, MPH, CPH

Objective To provide the Ryan White Planning Council with information necessary for FY 2017 priority setting and allocation

The Indianapolis Transitional Grant Area (TGA)

Indianapolis TGA Population Ten Central Indiana counties with an estimated population of 1.86 million 1 (6% increase since 2010) 2 3

TGA Population Center 88% of the TGA’s population in orange 4 46% reside inside Indianapolis city limits 1

Overview of Part A and Minority AIDS Initiative (MAI) Funding

Overview of Part A and MAI Funding Part A Funding = Formula + Supplemental 5 Formula funds are based on the number of people living with HIV/AIDS (PLWH/A) in the TGA Supplemental funds are awarded competitively based on demonstrated need and other selective criteria Includes core medical and support services designed to provide a continuum of care for PLWH/A Core Medical Must account for at least 75% of Part A funds allocated for services Support Services Must be linked to the continuum of care and cannot exceed 25% of Part A funds allocated for services unless a waiver is obtained

Overview of Part A and MAI Funding MAI Funding 5 Funding based on distribution of PLWH/A among racial/ethnic minorities residing in the TGA Supports services for minority populations Data Sources Utilization data collected using the Ryan White Information Services Enterprise (RISE) database 6 Clinical and outcomes data collected using RISE and the Enhanced HIV/AIDS Reporting System (eHARS) database 7

All Parts Spending in the Indianapolis TGA

Part A and MAI Service Utilization

Part A/MAI Utilization: FY 2015 During FY 2015: 2,549 unique clients utilized 26,825 units of service excluding EIS testing and 7,858 residents were tested for HIV Core Medical accounted for 62.7% of Part A/MAI service units and 77.6% of non-administration dollars spent at an average cost of $116 per unit Support Services accounted for 37.3% of Part A/MAI service units and 22.4% of non-administration dollars spent at an average cost of $67 per unit

Part A/MAI Utilization: FY 2015 vs. FY 2014 The number of clients and services utilized increased considerably during FY 2015 Number of clients increased 10% (2,549 v. 2,326) Number of EIS tests increased 53% (7,858 v. 5,132) Units of non-EIS service decreased <1% (26,825 v. 27,034) Cost per client decreased 13% ($1,378 v. $1,529)

Utilization of Core Medical Services

Utilization in FY 2015 v. FY 2014

Early Intervention Services (EIS) Accounted for 22.7% of Part A/MAI services utilized and 13.8% of dollars spent Utilized by 7,858 clients, an increase of 53% from FY14 (N=5,132 ) Always 1.0 service unit per client Averaged $61 per client, a decrease of 12% from FY14 ($70)

Medical Case Management (Including Treatment Adherence) Accounted for 16.5% of Part A/MAI services utilized and 23% of dollars spent Utilized by 1,980 clients, an increase of 13% from FY14 (N=1,750 ) Averaged 2.9 service units per client, a decrease of 9.6% from FY14 (N=3.2) Averaged $394 per client, an increase of 9% from FY14 ($360)

Outpatient Ambulatory/Primary Medical Care Accounted for 14.3% of Part A/MAI services utilized and 19.7% of dollars spent Utilized by 518 clients, a decrease of 43% from FY14 (N=908 ) Averaged 9.6 service units per client, an increase of 68.2% from FY14 (N=5.7) Averaged $1,296 per client, an increase of 50% from FY14 ($861)

Mental Health Services Accounted for 4.8% of Part A/MAI services utilized and 3.9% of dollars spent Utilized by 290 clients, an increase of 1.4% from FY14 (N=286 ) Averaged 5.7 service units per client, a decrease of 12% from FY14 (N=6.5) Averaged $473 per client, a decrease of 5.8% from FY14 ($502)

Oral Health Care Accounted for 1.8% of Part A/MAI services utilized and 2.5% of dollars spent Utilized by 132 clients, a decrease of 31% from FY14 (N=191 ) Averaged 4.8 service units per client, a decrease of 6.4% from FY14 (N=5.1) Averaged $668 per client, a decrease of 14.4% from FY14 ($780)

AIDS Pharmacy Assistance (Local) Accounted for 0.7% of Part A/MAI services utilized and 4% of dollars spent Utilized by 99 clients, a decrease of 38% from FY14 (N=160 ) Averaged 2.3 service units per client - no change from FY14 Averaged $1,404 per client, a decrease of 6% from FY14 ($1,494)

Health Insurance Premium & Cost Sharing Assistance Accounted for 1% of Part A/MAI services utilized and 5.2% of dollars spent Utilized by 48 clients, an increase of 20% from FY14 (N=40 ) Averaged 7.1 service units per client, an increase of 550% from FY14 (N=1.1) Averaged $3,792 per client, a decrease of 4.5% from FY14 ($3,969)

Substance Abuse Services Accounted for 0.9% of Part A/MAI services utilized and 1.4% of dollars spent Utilized by 44 clients – no change from FY14 Averaged 7.5 service units per client, a decrease of 2.9% from FY14 (N=7.7) Averaged $1,076 per client, an increase of 2.3% from FY14 ($1,052)

Nutrition Services Accounted for <0.5% of Part A/MAI services utilized and <0.5% of dollars spent Utilized by 13 clients – Not utilized in FY14 Averaged 1.1 service units per client Averaged $72 per client

Utilization of Support Services

Utilization in FY 2015 v. FY 2014

Non-Medical Case Management Accounted for 16.6% of Part A/MAI services utilized and 12.5% of dollars spent Utilized by 2,223 clients, an increase of 29.2% from FY14 (N=1,721) Averaged 2.6 service units per client, a decrease of 4.2% from FY14 (N=2.7) Averaged $191 per client, an increase of 0.6% from FY14 ($190)

Health Education/Risk Reduction (HE/RR) Accounted for 9.6% of Part A/MAI services utilized and 2.4% of dollars spent Utilized by 1,110 clients, a decrease of 16.4% from FY14 (N=1,328) Averaged 3.0 service units per client – no change from FY14 Averaged $76 per client, an increase of 21.3% from FY14 ($62)

Outreach Services Accounted for 1.3% of Part A/MAI services utilized and 2% of dollars spent Utilized by 449 clients, an increase of 532% from FY14 (N=71) Averaged 1.0 service units per client, a decrease of 75% from FY14 (N=4.0) Averaged $158 per client, a decrease of 81% from FY14 ($832)

Emergency Financial: Food Accounted for 2.6% of Part A/MAI services utilized and 0.9% of dollars spent Utilized by 409 clients, a decrease of 5.3% from FY14 (N=432) Averaged 2.2 service units per client, an increase of 4.3% from FY14 (N=2.1) Averaged $78 per client, an increase of 10.1% from FY14 ($71)

Medical Transportation Services Accounted for 4.5% of Part A/MAI services utilized and 1.5% of dollars spent Utilized by 344 clients, an increase of 17.8% from FY14 (N=292) Averaged 4.5 service units per client, a decrease of 8.3% from FY14 (N=4.9) Averaged $157 per client, a decrease of 22.2% from FY14 ($201)

Short Term Housing Accounted for 0.5% of Part A/MAI services utilized and 3.1% of dollars spent Utilized by 162 clients, an increase of 7.3% from FY14 (N=151) Averaged 1.2 service units per client, a decrease of 17.5% from FY14 (N=1.4) Averaged $669 per client, a decrease of 0.4% from FY14 ($672)

Emergency Financial: Utilities Accounted for 0.5% of Part A/MAI services utilized and 1.1% of dollars spent Utilized by 125 clients, a decrease of 16.7% from FY14 (N=150) Averaged 1.4 service units per client, a decrease of 3.5% from FY14 (N=1.5) Averaged $297 per client, a decrease of 4.9% from FY14 ($312)

Psychosocial Services Accounted for 0.7% of Part A/MAI services utilized and 0.8% of dollars spent Utilized by 62 clients, a decrease of 24.4% from FY14 (N=82) Averaged 3.8 service units per client, a decrease of 48% from FY14 (N=7.3) Averaged $445 per client, a decrease of 8.2% from FY14 ($485)

Legal Services Accounted for 0.6% of Part A/MAI services utilized and 0.6% of dollars spent Utilized by 61 clients, a decrease of 23.8% from FY14 (N=80) Averaged 3.4 service units per client, an increase of 10% from FY14 (N=3.1) Averaged $362 per client, an increase of 15.1% from FY14 ($315)

Linguistic Services Accounted for 0.4% of Part A/MAI services utilized and 0.3% of dollars spent Utilized by 44 clients, an increase of 83.3% from FY14 (N=24) Averaged 3.3 service units per client, a decrease of 42.8% from FY14 (N=5.8) Averaged $256 per client, a decrease of 42.2% from FY14 ($443)

Part A/MAI Client Profile

Client Status and Time Enrolled During FY 2015, a total of 2,549 unique clients utilized Part A and/or MAI services Of clients served, 67.9% (N=1,730) have an active client status, an increase of 4% over FY 2014 Of unique clients served, 11.0% (N=280) applied for and accessed Ryan White services for the first time – Up from 10% last year Clients were enrolled from <1 to 52 weeks with an average duration of 17.5 ± 8.6 weeks

Part A/MAI Clients by Enrollment Status

Part A/MAI Clients by Gender

Part A/MAI Clients by Current Age

Part A/MAI Clients by Race/Ethnicity N missing = 96

Part A/MAI Clients by HIV Status

Part A/MAI Clients by Exposure Category

Part A/MAI Clients by Poverty Level N missing = federal poverty level was $11,770 for single-person households 8

Part A/MAI Clients by County of Residence During FY 2015, 44.9% of PLWH/A in the TGA utilized Part A/MAI services (2,549 of 5,674) 49% of Marion County PLWH/A accessed services 20% of PLWH/A in the outlying counties accessed services N missing = 11

HIV Continuum of Care in the TGA

HIV Care Continuum Definitions Linked to Care: People newly diagnosed with HIV during 2015 who received a CD4/viral load test within 90 days HIV Prevalence: Estimated number of HIV+ residents at EOY 2015, including those undiagnosed and unaware of their status Diagnosed: Number of diagnosed HIV+ residents at EOY 2015 Retained in Care: Diagnosed residents with 2+ CD4/viral load tests performed at least 3 months apart in 2015 Antiretroviral Therapy: Diagnosed residents who received a prescription for antiretroviral therapy in 2015 *Estimated* Viral Load Suppression: Diagnosed residents with a viral load result <200 RNA copies/mL in 2015

HIV Care Continuum in the TGA MeasureNumeratorDenominatorPercent Linked to Care % HIV Prevalence 6, % Diagnosed 5,6746, % Retained in Care 2,8025, % Antiretroviral Therapy* 2,5895, % Viral Load Suppression 3,3785, %

Ryan White Clients v. Non-Client PLWH/A

Community Viral Load Geometric means were used for comparison of viral load between Ryan White clients (all parts) versus non-client PLWH/A in the TGA Geometric means are always smaller than arithmetic means because the effect of very large values is diminished Geometric means are more stable from year to year All results are based on the last reported viral load test during 2015 for residents with ≥1 viral load test Results were standardized such that: Results reported as 0 or <20 were set to half the lower limit of detection possible for the assay used according to CDC recommendations 28

Community Viral Load by RWSP Status Number and percent with suppressed viral load (<200 RNA copies/mL) at last CY 2015 test, by Ryan White HIV Services Program enrollment status RWSP Enrollment Status: CY 2015N % at <200 copies/mL Geometric Mean Viral Load 95% Confidence Interval (GM) Not Enrolled1, Enrolled Part of the Year1, Enrolled All Year ^ 1, ^ Experienced <30 day enrollment lapse during the year of interest

Michael Wallace Director Tammie L. Nelson, MPH, CPH Epidemiologist Ryan White HIV Services Program Health & Hospital Corporation Marion County Public Health Department

References 1 U.S. Census Bureau. (2016). Annual estimates of the resident population: April 1, 2010 to July 1, U.S. Census Bureau, Population Division. Release dates: For the United States, regions, divisions, states, and Puerto Rico Commonwealth, December 2015; For counties and Puerto Rico municipios, March U.S. Census Bureau. (2002). Time series of Indiana intercensal population estimates by county: April 1, 1990 to April 1, Table CO-EST Release date April 17, U.S. Census Bureau. (2011). Intercensal estimates of the resident population for counties of Indiana: April 1, 2000 to July 1, Table CO-EST00INT Glenn, R. (2011). Demographics & trends: Indianapolis, Marion County & the Indianapolis region. Department of Metropolitan Development: City of Indianapolis. 5 Health Resources and Services Administration. (2014). About the Ryan White HIV/AIDS program – About Part A: Grants to emerging metropolitan & transitional grant areas. Washington D.C.: U.S. Department of Health and Human Services. Available at 6 Ryan White HIV Services Program. (2014). Ryan White Information Services Enterprise (RISE). Indianapolis: Marion County Public Health Department. 7 Centers for Disease Control and Prevention. (2014). Enhanced HIV/AIDS Reporting System (eHARS). Indianapolis: Indiana State Department of Health. 8 U.S. Department of Health & Human Services. (2015) poverty guidelines. Retrieved from