The New York City Department of Health and Mental Hygiene (DOHMH), Bureau of Public Health Clinics (BPHC) operates eight sexual health clinics that provide walk-in STI and HIV testing, treatment, and linkage to community providers for ongoing care. The clinics, which are not funded through the Ryan White HIV/AIDS Program (RWHAP), receive city, state, and other federal dollars. BPHC (formerly the Bureau of Sexually Transmitted Infections) launched JumpstART in 2016 as part of New York State’s Ending the Epidemic initiative, changing the clinics’ service delivery model to include an initial prescription of antiretroviral therapy (ART) after an HIV diagnosis and prior to linkage to the community provider. In a retrospective cohort study of people with a new diagnosis of HIV between November 2016 and September 2018, BPHC found that 60% of JumpstART clients received ART on the same day as diagnosis. JumpstART clients were also more likely to reach viral suppression within three months compared to non-JumpstART clients.
New York City, NY
The sexual health clinics operated by BPHC had historically provided STI and HIV testing, treatment of STIs and other acute conditions, and partner services. Clinics shifted their focus to encompass broader sexual health services, including reproductive health care, pre-exposure prophylaxis (PrEP), and ART. The change aligned with New York City’s status-neutral initiative, defined by the Centers for Disease Control and Prevention (CDC) as “a whole person approach to HIV prevention and care that emphasizes high-quality care to engage and retain people in services regardless of if the services are for HIV treatment or prevention.”1
The sexual health clinics conduct walk-in HIV testing. During the COVID-19 pandemic, clinics started offering home test kits, but most testing occurs onsite. About 90% of clients who come to a clinic receive an HIV test. A patient navigator or social worker meets with the client to share test results, discuss JumpstART, and connect the client to an available clinician.
A clinician (physician or nurse practitioner) meets with the client to prescribe ART and request additional lab work (e.g., hepatitis C, HIV genotype, CD4 count, and viral load). The clinician submits an electronic prescription to a local pharmacy, and the patient navigator or social worker calls to confirm that the insurance was accepted and the prescription is ready. Either the pharmacy delivers the prescription, or the patient navigator or social worker walks the client to the pharmacy to pick up the prescription.
The patient navigator or social worker discusses insurance options with the client and facilitates enrollment into Rapid TX, a state program that provides immediate coverage for 30 days if uninsured. The social worker or patient navigator also conducts an assessment of social needs and links the client to services, primarily through other city programs. The client also meets with a social worker to address mental health concerns.
New York City’s sexual health clinics provide HIV testing and immediate treatment and then refer clients to community providers for ongoing HIV care. The patient navigator or social worker helps the client select the best community provider based on location, language spoken, and other clinical needs such as gender-affirming or specialty care. The patient navigator or social worker schedules the first appointment three weeks from the date of diagnosis, shares client lab results once they are back from the public health lab (typically within three to five days), and reminds the client about the appointment. The community provider then communicates with the sexual health clinic about whether the client came in for the appointment. If a client receives an abnormal lab from the initial panel taken on the day of diagnosis, the sexual health clinic reaches out to the client and the community provider to expedite care.
BPHC conducted a retrospective cohort study of people diagnosed between November 2016 and September 2018, matching JumpstART clients with non-participating clients from HIV surveillance data. BPHC found that 60% of JumpstART clients received ART on the same day as diagnosis. BPHC also found that within three months of diagnosis, 83% of JumpstART clients were virally suppressed compared to 45% of non-JumpstART clients.
| Category | Information |
|---|---|
| Evaluation data | The sexual health clinics modified BPHC’s existing electronic health record (EHR) system to capture fields related to rapid ART, including prescriptions and reason for client denials. The study also used HIV surveillance data. |
| Measures |
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| Results |
* statistically significant |
Source: Pathela P, Jamison K, Braunstein SL, et al. Initiating antiretroviral treatment for newly diagnosed HIV patients in sexual health clinics greatly improves timeliness of viral suppression. AIDS. 2021;35(11):1805–1812.
Jurisdiction support. In 2015, the governor of New York State, in partnership with HIV care advocates and stakeholders, launched a plan to end the HIV epidemic by 2020. This involved an expansion of services throughout the state, including the prevention and treatment of HIV in New York City’s sexual health clinics (previously known as STD clinics). The state and city provided funding to advance this ambitious plan, which allowed BPHC to hire additional clinicians and patient navigators. Further, the AIDS Institute of the New York State Department of Health changed recommended guidelines to encourage ART prescription immediately after diagnosis. Finally, the state implemented a program called Rapid TX, which provides coverage for medication and care for 30 days until enrollment into the AIDS Drug Assistance Program (ADAP) or a health care coverage program (e.g., Medicaid) can occur.
Clinical appointment availability. Clinics have always seen clients on a walk-in basis and, therefore, did not have to change their model to accommodate JumpstART clients. However, BPHC hired many new clinicians, primarily nurse practitioners with experience in HIV, to increase the capacity of clinics to prescribe ART and PrEP. Currently, three to five clinicians are on duty at a given sexual health clinic at a time. While this number is typically sufficient, clinicians reported that JumpstART client appointments can take two to three hours, which can affect clinic capacity.
Same-day medication. BPHC partners with local pharmacies to ensure that clients access medication on the day of diagnosis. Typically, partner pharmacies deliver medications to the clinic within 30 minutes of prescribing, so clients can leave with them “in hand.” Given the density of New York City, pharmacies are usually within a block or two of the clinics.
Payment for medications. JumpstART primarily relies on insurance reimbursement for the cost of medications, including the state Rapid TX program that provides immediate coverage for 30 days. A patient navigator or social worker works closely with clients before and during their initial visit to establish eligibility for Rapid TX and for long-term coverage, including Medicaid and ADAP. Pharmacies bill the insurance program directly to cover the cost of ART. Starter packs purchased through BPHC’s budget are also available if needed, in addition to co-pay support provided by drug manufacturers.
Staff training. JumpstART implemented an extensive training effort, tailored to staff type. Clinicians were trained on HIV and advancements in treatment. Patient navigators, who were hired via the civil service process and therefore may have had little experience with HIV, were trained on communicating HIV test results, strategies for educating people on HIV, harm reduction, trans-affirming care, and addressing their own biases related to HIV, substance use, and mental illness. BPHC partnered with several outside organizations to ensure that the people conducting the training had direct experience providing care to people with HIV.
The sexual health clinics rely on city, state, and federal funding, with the city providing ongoing funding for the clinics’ annual budget. State grant funding under the Ending the Epidemic initiative is provided in five-year cycles. Finally, BPHC received funding from M·A·C AIDS Fund for medication starter packs and training. Pharmacies bill insurance programs for the cost of medications.
- Initially, clinics relied solely on medication starter packs, but turned to a model where medications were covered by insurance and dispensed by local pharmacies, for financial sustainability. Based on agency policy, the New York City DOHMH cannot accept sample donations from pharmaceutical manufacturers, a common strategy used by other organizations with rapid ART programs. As a result, New York City DOHMH had to purchase all starter packs, which put a financial strain on the program. The move to pharmacy-dispensed medications represented a major shift from the previous model. Under JumpstART, BPHC created a system for clinicians to write electronic prescriptions and built a network of partner pharmacies.
- JumpstART was driven by the highest levels of state government. The governor laid out a “blueprint” for ending the HIV epidemic, and leadership within the New York City DOHMH played an essential role in identifying sexual health clinics as a focal point for HIV treatment and prevention.
- JumpstART represented a significant shift in service delivery for the sexual health clinics. While many clinic staff members were eager to implement JumpstART so they could help their clients receive care “faster,” other staff were hesitant to change the status quo. In addition, many existing and newly hired staff needed to be trained on HIV and new protocols for care delivery under JumpstART. Training helped address these issues.
“And here we are six years later, and it's like we're still changing things. So, it's better to just do it and figure things out as you go along and tweak. [You can’t be perfect before implementation], because even if you plan for it to be, it won't be.”
