Philadelphia public health officials have an ambitious goal: cutting HIV diagnoses by 75% in the next five years.

To achieve that, they are trying a new tactic. Rather than conducting as many tests as possible, both federal and city agencies are increasing testing in high-risk populations, such as men who have sex with men (MSM), Black and Latino people, transgender people, and those who inject drugs.

“We have years and years of looking at the traditional model where the concept is, get HIV tests out into the community and the more tests we do, the more people we’ll find that are unaware of their status,” said Alecia Manley, executive operating officer of the Mazzoni Center. This model was like “fast food,” Manley added: convenient and able to serve large numbers of customers.

But like fast food, it didn’t fill all the community’s needs. In 2019, there were 439 new HIV diagnoses in Philadelphia, and more than 50% were in MSM. Yet, only 24% of tests that year were conducted in that group. Estimates from 2018 suggest that 1,700 more people, including 1,000 MSM, may be HIV-positive but unaware of their status.

The agencies are shifting millions in public dollars behind this new strategy, with some of the city’s busiest test sites losing funding while others are getting their first grants.

“Historically, many agencies have not been reaching the populations that are the greatest priorities at greatest risk of exposure,” said Kathleen Brady, acting director and medical director at the Philadelphia Department of Public Health’s AIDS Activities Coordinating Office (AACO). “If we continue funding the same programs and don’t make any changes, we won’t make any headway.”

Traditionally, resources have been focused on free rapid testing as a standalone service. But a new plan — taking cues from the Centers for Disease Control and Prevention and successes in New York City — centers on comprehensive sexual health clinics. For example, a patient who comes in for a pregnancy test may also get an HIV test or screening for a broader panel of STIs.

In the traditional model, patients with a positive HIV test might see a lag before starting treatment. But at full-service clinics, they will be able to start almost immediately, and patients who test negative will have easy access to prevention consults.

AACO has earmarked $2 million of its more than $3.4 million HIV testing budget in 2021-22 for four clinics catering to priority populations: LGBTQ, Black, and Latino people, and residents of Southwest Philadelphia. These sites will offer HIV testing as part of culturally competent sexual health care and education.

The Mazzoni Center, an LGBTQ health center, received a new grant to expand offerings at its Washington West Project clinic. But shifting funds to Washington West, combined with losing a CDC grant that has supported its HIV testing for two decades, meant a $500,000 hit this year. Last week, Mazzoni announced that it was laying off 11 employees, reducing capacity for HIV testing and STI screening by 70%, Manley said.

Although this will make a significant dent in the 7,500 HIV tests and 10,000 STI screens that Mazzoni conducts annually, Brady noted that many people will still be able to get tested in primary care settings.

“Maybe we’re doing less tests but we’re doing a better job of testing the folks that need to be tested,” Manley said.

The city’s data back this up, Brady said. In 2019, the vast majority of HIV diagnoses were made in hospitals and other medical settings. Even with more than $2 million in AACO funding, 12 community-based organizations made only a combined 24 diagnoses.

But integrated sexual health clinics such as Washington West seemed to fare better. In 2019, three of these clinics — with a total of $1 million in AACO funding — diagnosed 69 HIV-positive patients. This comes out to a cost of roughly $14,000 per diagnosis at the clinics, compared with more than $80,000 through traditional testing, Brady noted.

So far, AACO has funded three sexual health clinics and nine other community-based testing sites for 2021-22, with the new guidelines prompting traditional sites also to focus on high-risk populations. For some groups, such as Prevention Point Philadelphia, a public health organization based in Kensington, this is a welcomed boost to their work with clients who have substance use disorder.

Prevention Point clients usually come to mobile and brick-and-mortar sites for other services, such as syringe exchange, said José Benitez, executive director, and staff encourage them to get tested for HIV, too, but couldn’t always offer it immediately. With new AACO funding, Prevention Point will be able to offer HIV testing at all of its sites and open an HIV clinic to link clients to follow-up care.

Congreso de Latinos Unidos will be focusing its efforts in northwest Philadelphia by using new CDC funding to hire specialists who will offer new support services for clients who test negative for HIV but are at high risk due to injection drug use.

Bebashi — a North Philadelphia organization founded in the ’80s to respond to the AIDS crisis among communities of color — has been awarded its first CDC grant: more than $400,000 a year for five years. It will focus grant dollars on HIV treatment, education, and testing more than 10,000 MSM and transgender people of color.

“We target those people who are most at risk,” said Sebrina Tate, executive director of Bebashi.

After failed funding attempts in the past, Tate thinks connections to MSM, Black, and transgender communities helped Bebashi stand out. She also thinks continuous service throughout the COVID-19 pandemic was key. Bebashi was one of the few local organizations to continue on-site HIV testing.

“That was our way of engaging the community at a time when HIV testing numbers weren’t as robust,” Tate said. “We saw ourselves as essential.”

Tatyana Woodard, a prevention community outreach manager at Mazzoni, said community engagement is also crucial work. “Some agencies have made folks feel like they’re just a number,” she said, noting that even if no test is done on the spot, engaging with a person might prompt them to take a test at a later time or in a different place.

At Bebashi, Tate agreed that testing is just part of the job.

“The number of people you’re able to engage in education workshops, the number of people who accept take-home tests,” she said. “Those are some of the secondary and tertiary statistics that may not appear on a grant but are a way in which you impact the community.”