Since 1994, NYU Grossman School of Medicine Part D program has provided family-centered, comprehensive, HIV/AIDS primary and specialty care; mental health, medical case management and supportive services to HIV-infected women, children, youth/young adults, and affected family members in Staten Island, and Manhattan through the Upper/Lower NYC HIV Consortium. Part D-funded medical providers include HHC Bellevue, HHC Metropolitan; Staten Island University Hospital; and Richmond University Medical Center of Staten Island. Target area: NYC counties Richmond and Manhattan. Target Population: mainly an African American (55%) and Hispanic (31%)) population of 600+ women, children, and youth living with HIV/AIDS and their affected family members. Of these, 43% were infected through heterosexual contact, 36% through men having sex with men (MSM), and 15% through maternal transmission. Key client SES characteristics include unemployment levels exceeding, and median family incomes, far below those in NYC. Problem: The Consortium collectively serves an area that encompasses 22% of NYC new HIV diagnoses, 27% of PLWHA, 18% of women living with HIV/AIDS and 20% of children, youth/young adults 0-29. The area accounts for 16% of NYC’s Black, 19% of Hispanic PLWHA, and 20% of youth/young adults ages 13 – 29. HIV/AIDS in NYC disproportionately affects minorities, women of color, the poor, MSM and high HIV incidence/prevalence neighborhoods served by the Consortium - Washington Heights/Inwood, Central and East Harlem, Greenwich Village, and Chelsea and high impacted neighborhoods of S. Bronx and Central Brooklyn. Richmond (Staten Island), southern most part of the catchment area, has few comprehensive HIV/AIDS agencies responding to its 2,547 PLWHA. Challenges: 1) While HIV infection is decreasing, increasing longevity resulting from improved treatments presents challenges to treating an aging population experiencing other chronic health conditions that complicate
living with HIV from within an often fragmented health care system lacking integrated care and services, especially for substance abuse treatment and mental health services; 2) retaining in care children aging into adolescence and young adulthood and newly infected youth, and infected adults with growing family responsibilities, often, faced with poverty, stigma, unemployment and now dealing with the medical, economic and social complications of the COVID-19 pandemic. Young MSM of color in NYC have the highest incident HIV infection and require tailored services to identify and retain them in care. HIV positive women, 92% of whom are minorities, often delay their care to address family needs and lack access to HIV prevention and testing and GYN services. Perinatally infected youth need skills to manage their care as they transition to adult care, and behaviorally infected youth require unique services in the absence of family and friends’ support. The Consortium helps clients address disclosure, stigma, treatment and appointment adherence, building self-care skills and mental health issues through medical case management and supportive services with the goal of improving health outcomes. Our program builds on 33 years of experience identifying and linking low income WICY to out-patient HIV testing and provision of comprehensive wrap around one-stop-shop of HIV/AIDS primary, specialty and GYN care, integrated mental health assessment and treatment, and providing information, education, and opportunities to participate in related clinical research and health education workshops. Goals:1) expand the current Part D patient census through community level outreach, HIV testing and linkage to care to family-centered care in outpatient/ambulatory care settings; and 2) utilize evidence informed interventions to increase viral load suppression rates, retention in care, and improve overall health of 600+ WICY and affected family members.