Some barriers to accessing HIV prevention and care are historic. But hurdles extend beyond history.
“Many current barriers to care and prevention are simply structural, such as not having enough HIV centers of excellence in areas where Black and Latino people live,” said Doug Wirth, CEO of Amida Care, a Midtown-based special-needs health plan for people living with HIV.
The ability to access testing, pre-exposure prophylaxis medication and treatment stem from a situation not unique to HIV, but rather rooted in social determinants of health issues, and the state has recognized that, said Johanne Morne, director of the AIDS Institute.
Even if referred for treatment, patients experiencing issues with social determinants of health need support such as transportation, stable housing and nutrition for the linkage to treatment to even work, Morne said.
Stigma could also drive patients who are people of color to desire care from providers not based in their neighborhoods, and inadequate access could thwart linkage to care too, said Dr. Ofole Mgbako, section chief of infectious diseases at NYC Health + Hospitals/Bellevue. “Black and Hispanic communities tend to face these barriers to care more starkly than other ethnic groups,” he added.
This year the state Department of Health and the AIDS Institute are prioritizing funding for initiatives that address that inequity in HIV, such as programs for aging individuals and people born with the disease as well as employment partnerships to provide livable wages, food and nutrition access, and housing support.
Gov. Kathy Hochul in November renewed the state’s commitment to achieving goals outlined in the Ending the Epidemic initiative by 2024. The state has earmarked $20 million toward that initiative since its inception in 2015. In her speech at the sixth annual Ending the Epidemic summit, Hochul acknowledged that communities of color and people of lower socioeconomic status are overrepresented for being at risk for HIV.
“These facts point to the persistence of structural and other forms of racism and inequality as important drivers of disparate health outcomes, despite the progress made overall,” she said.
Beyond initiatives to address social determinants of health, Hochul and the state have the ability to implement structural changes to elevate access to HIV care, Wirth said.
“For far too long, under the previous administration, Medicaid was undermined,” Wirth said, referring to former Gov. Andrew Cuomo, who proposed across-the-board 1.5% cuts to Medicaid reimbursement rates in fiscal 2021. Hochul’s proposed budget for fiscal 2023 would restore those cuts.
“You cannot deal with racism in healthcare without investing in Medicaid,” Wirth said, adding that communities of color are most likely to need state-sponsored coverage.
Reinvesting in Medicaid benefits community health centers that provide a full-spectrum of services that address social determinants of health, not just HIV care, Mgbako said.
Currently, providers contracting at the lowest level of value-based care with Medicaid do not need to account for social determinants of health needs of patients. The state Department of Health, however, has the ability to require that providers address social determinants of health even with a level-one contract as it is redesigning its Medicaid waiver program.
“The Cuomo administration had ignored many of the recommendations we and others in the industry have made,” Wirth said. “I’m tremendously excited by Hochul’s understanding that Medicaid is a primary means for addressing health inequities, especially in HIV.”
At the city level, the renewed focus on health equity is promising. The city Health Department’s appointment of Dr. Michelle Morse as its first chief medical officer, who will also head the agency’s Center for Health Equity and Community Wellness, means initiatives to improve HIV disparities for communities of color are forthcoming, Mgbako said.
The road ahead will be rocky as COVID continues to threaten progress. HIV testing decreased in 2020, and pre-exposure prophylaxis medication uptake and rates of people who achieved viral suppression decreased, said Tesoriero from the AIDS Institute.
“It will get a little worse before we can get to where we need to be,” he said.
This story first appeared in our sister publication, Crain's New York Business.