2010-2013 San Diego County Plan For HIV Prevention Services

Plan for HIV Education and Prevention Services for San Diego County 2010-2013
Prepared by the HIV Prevention Community Planning Group in conjunction with the County of San Diego Health and Human Services Agency, HIV, STD and Hepatitis Branch of Public Health Services May 2010
Plan for HIV Education and Prevention Services for San Diego County 2010-2013
Developed by the San Diego County HIV Prevention Community Planning Group
In Partnership with the County of San Diego Health and Human Services Agency HIV, STD and Hepatitis Branch of Public Health Services
Prepared by Jae Egan Lori Jones Dan Uhler
May 2010
Plan for HIV Education and Prevention Services for San Diego County, 2010-2013
FOREWORD In 2008, the San Diego County HIV Prevention Community Planning Group (Prevention Group) and the HIV, STD and Hepatitis Branch (HSHB) of Public Health Services began the community planning process for HIV education and prevention services for 20102013. At that time, the community planning process and plan were mandated by the Centers for Disease Control and Prevention (CDC) and the California Department of Public Health, Office of AIDS (CDPH/OA). In 2009, due to State of California budget cuts, the CDPH/OA while continuing to support local community planning no longer mandated a community planning process or planning group. In San Diego County, the community planning process for HIV education and prevention continues intact and is dedicated to ensuring that services funded through HSHB are evidence-based and relevant to the communities they serve. Two years have passed since the journey began, and the end result is a testament to what a community can do when committed to a shared goal. The Plan for HIV Prevention Services for San Diego County 20102013 would not have been possible without the collaborative efforts of the local planning group, advisory groups and community members and the many others who have helped sustain it. This plan represents the culmination of thousands of hours of service to the idea that HIV is a preventable disease when a community of diverse individuals concerned about each other works together to achieve a common goal. This plan guides the HIV education and prevention services administered by the County of San Diego. In alignment with CDCs HIV Prevention Community Planning Guide (U.S. Centers for Disease Control and Prevention [CDC], 2003) and in the context of diminishing resources, the intent of this plan is to focus efforts on those activities that are the most effective with populations that can be accessed and are at the highest risk for transmitting or contracting HIV. We acknowledge that while this plan can not begin to meet all the HIV prevention needs in San Diego County, we, along with HSHB, fully support all community-based efforts to seek funding and continue to discover innovative ways to meet the needs of our community. The intent of this plan is to not only guide local planning for HIV education and prevention services but to serve as a resource and reference for those seeking funding and working to prevent HIV in San Diego County. The HIV epidemic in San Diego continues to be driven by exposure through unsafe sex practices and injection drug use. This plan acknowledges that working with HIV positive individuals in maintaining safer behaviors is necessary if we hope to decrease the impact and end this evolving epidemic. This plan includes sections with practical applications to address HIV prevention activities, strategies to address barriers for specific populations and future directions for the Prevention Group, HSHB, and our providers and partners. It is a living document that may be amended as new or updated information is available. Thank you, The membership of the HIV Prevention Community Planning Group
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TABLE OF CONTENTS Foreword ......................................................................................................................... 3 List of Tables................................................................................................................... 7 List of Figures.................................................................................................................. 9 Letter of Concurrence.................................................................................................... 11 Acknowledgements ....................................................................................................... 13 Mission, Vision and Strategic Plans .............................................................................. 15 A Look at San Diego County ......................................................................................... 17 History of HIV Education and Prevention Services ....................................................... 21 HIV Education and Prevention Community Planning Process ...................................... 29 HIV Education and Prevention Priority Populations and Definition of Highest-Risk Individuals and Activities .......................................................................... 53 HIV Education and Prevention Goal and Objectives ..................................................... 57 Barriers and Strategies to Address Barriers for HIV Education and Prevention Services ...................................................................................................... 61 Future Directions for HIV Education and Prevention Services ...................................... 73 References.................................................................................................................... 81 Appendices ................................................................................................................... 85 A. Guiding Principles for Effective HIV Prevention Interventions ............................ 87 B. HIV Prevention Interventions and Strategies ...................................................... 91 C. Health Behavior Theories and Models.............................................................. 101 D. HIV Education and Prevention Resource Inventory.......................................... 111 E. Meth Strategies Organizational Chart............................................................... 125 F. Meth Resources Directory ................................................................................ 139 G. Gap Analysis and Summary FY 2008/2009...................................................... 155 H. Partner Services Summary............................................................................... 169 I. 2010 Needs Assessment Summary ................................................................. 173 J. HIV Prevention Funding FY 2009/2010 ............................................................ 189
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K. Glossary of Acronyms ...................................................................................... 195 L. Glossary of Terminology................................................................................... 199 M. HIV and STD Education and Prevention Services Brochure ............................ 203
LIST OF TABLES Table 1 Distribution of the General Population by Age Group and Gender, County of San Diego, 2008............................... 17 Distribution of the General Population by Race/Ethnicity and Gender, County of San Diego, 2008 ......................... 18 Distribution of the General Population by Race/Ethnicity and Region, County of San Diego, 2008.......................... 20 HIV Education and Prevention Community Planning Cycles ................... 22 HIV Education and Prevention Funding Sources and Amounts by Fiscal Year............................................................................................... 27 San Diego County HIV Prevention Community Planning Group 2009 Membership Survey ........................................................................ 38 San Diego County HIV Prevention Community Planning Group 2010 Community Planning Process Evaluation of Goals ......................... 45 San Diego County HIV Prevention Community Planning Group 2010 Community Planning Process Evaluation of Components .............. 46 Step by Step HIV Education and Prevention Community Planning Process Summary..................................................................... 51 San Diego County Ranked HIV Education and Prevention Priority Populations 2010-2013................................................................ 54 Barriers and Strategies: All Populations Engaged in Highest-risk Activities............................................................ 61 Barriers and Strategies: Men Who Have Sex with Men (MSM) Behavioral Risk Group ............................................................................. 64 Barriers and Strategies: Injection Drug Users (IDUs) Behavioral Risk Group ............................................................................. 65 Barriers and Strategies: Partners of MSM and/or IDUs Behavioral Risk Group ............................................................................. 65 Barriers and Strategies: African Americans Engaged in Highest-risk Activities............................................................ 66
Table 2
Table 3
Table 4 Table 5
Table 6
Table 7
Table 8
Table 9
Table 10
Table 11
Table 12
Table 13
Table 14
Table 15
Table 16
Barriers and Strategies: HIV Positive Individuals Engaged in Highest-risk Activities............................................................ 67 Barriers and Strategies: Latinos Engaged in Highest-risk Activities............................................................ 68 Barriers and Strategies: Transgender Engaged in Highest-risk Activities............................................................ 69 Barriers and Strategies: Women Engaged in Highest-risk Activities ........................................................... 70 Barriers and Strategies: Youth Engaged in Highest-risk Activities ........................................................... 72
Table 17
Table 18
Table 19
Table 20
LIST OF FIGURES Figure 1 Figure 2 Flow of Accountability for HIV Education and Prevention Services ......... 30 HIV Education and Prevention Community Planning Group Structure .... 37
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ACKNOWLEDGEMENTS This plan is the result of a lengthy process in which many people participated. We would like to take this opportunity to acknowledge the hard work and dedication of all involved. The following list of individuals and organizations reflects those who, in one way or another, have contributed to this document and efforts to prevent HIV in San Diego County.
Current HIV Prevention Community Planning Group Members Heidi Aiem Joselyn Harris Antonio Muoz Chris Thomas John Bevis Kim Herbstritt S. G. Reichen Veronica Tovar Michael Bursaw Tami Hudson Luis Salazar Jorge Velsquez Allegra Conway Lori Jones Carol Sipan Kartavya Vyas Catrina Flores Rev. Ikenna Kokayi Jan Stankus Jennifer Wheeler Felipe Garcia John Kua Micha Suarez Carl Wolter Michael Giancola Michael Lamont Michael Taylor Wilma Wooten Past HIV Prevention Community Planning Board Members Ernie Awa Carolina Gonzalez-Garcia Louise Lecklitner Deborah Paul Elizabeth Brosnan Robert Gunn Jaimie Morse Wayne Rafus Kevin Collin Geneva James Lisa Nelson Dan Uhler Katherine Crow Sheri Kirshenbaum Rosemari Ochoa Current HSHB and other County Staff Members Heidi Aiem Lorri Freitas Lori Jones Terry Cunningham Ken Katz Samantha Tweeten Jae Egan Dan OShea Dan Uhler Consultants Lisa Asmus Joel Knowles San Diego Association of Governments Doug Braun-Harvey Ian Roche Dr. Davey Smith Leticia Cazares Diego Rogers Loran Thompson HSHB Contracted HIV Education and Prevention Service Providers Family Health Centers of San Diego San Diego Youth Services The LGBT Community Center Stepping Stone of San Diego San Ysidro Health Center Vista Community Clinic Advisory Groups, Community Coalitions and Prevention Group Committees Prevention Strategies & Evaluations Committee HIV CARE Partnership South Bay Strategic Planning Team Coalition of Latino AIDS Service Providers Steering Committee Continuum of Care Committee Epidemiology & Target Populations Committee Target Populations Working Group Trans Action Advisory Group Faith-Based Working Group Transgender Advocacy and Services Center HIV Health Services Planning Council Youth Council Kemet Coalition North County Strategic Planning Group Special Thanks to
Tom Gray, who authored the Comprehensive Plan for HIV Prevention Services for San Diego County 2004-2007, and Asher Santos who authored the Comprehensive Plan for HIV Prevention Services for San Diego County 2007-2010. Parts of these previous plans were retained for this document. 13
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MISSION, VISION AND STRATEGIC PLANS HIV PREVENTION COMMUNITY PLANNING GROUP
Adopted June 1996; revised May 2007 and May 2010
Mission of HIV Prevention Community Planning Group The mission of the San Diego County HIV Prevention Community Planning Group (Prevention Group) is to improve health, inclusive of sexual health, through risk reduction activities and prevent new HIV infections in the County.
HIV, STD AND HEPATITIS BRANCH OF PUBLIC HEALTH SERVICES

Adopted June 1998; revised May 2007 and May 2010
Mission of HIV, STD and Hepatitis Branch of Public Health Services The mission of the HIV, STD and Hepatitis Branch of Public Health Services (HSHB) is to plan and deliver quality medical and supportive services to improve health, inclusive of sexual health, addressing HIV, STD and hepatitis in diverse communities that are infected, affected and at-risk for these diseases with an emphasis on the prevention of new infections in San Diego County. Vision of HIV, STD and Hepatitis Branch of Public Health Services We envision a future where members of our community are healthy and diseases, including HIV, STD and hepatitis are detected, treated and eliminated. As we work towards this vision, people living with these diseases will be empowered to move towards independence and self-sufficiency. Our vision includes: Promoting health, inclusive of sexual health; Preventing diseases; Decreasing infections, disease progression and death rates; Integrating services to effectively serve those infected and affected; Decreasing social discrimination; and Increasing opportunities for a better quality of life. Strategic Plan for HIV Prevention of HIV, STD and Hepatitis Branch of Public Health Services
Excerpted from County of San Diego Health and Human Services Agency (HHSA), Public Health Services Strategic Plan 2009-2014; Program Goal 7
Goal: Oversee the local allocation and distribution of funds to prevent the transmission of HIV through improving health outcomes, inclusive of sexual health outcomes, targeting those priority populations at the highest risk for infection. Strategy 1. Support the Prevention Group in the community planning process to develop an HIV education and prevention plan that establishes recommendations for and prioritizes populations in accordance with community needs, and guidelines and mandates from the California Department of Public Health, Office of AIDS (CDPH/OA) and Centers for Disease Control and Prevention (CDC).
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Objective 1.1 Develop a plan for HIV education and prevention services for San Diego County every three years. Monitor and update the current plan and approve by HSHB and the Prevention Group a revised plan for 2010-2013 by July 1, 2010. Upon approval, implement and monitor plan and begin working on the 2013-2016 plan. Strategy 2. Develop scopes of work (SOW) for contracted services for the prevention of HIV and STDs and monitor for progress and compliance. Objective 2.1 Submit reports with summary of progress on meeting contract objectives twice a year to CDPH/OA in February and August for the six-month period prior and once a year to the Prevention Group in November for the previous fiscal year (July 1-June 30). Strategy 3. Continue to require and monitor the provision of services to promote health, inclusive of sexual health, of partners of individuals living with HIV through Partner Services (PS) by all contracted HIV education and prevention service providers. Objective 3.1 Submit reports with summary of progress on meeting contract objectives twice a year to CDPH/OA in February and August for a six month period prior and once a year to the Prevention Group in November for the previous fiscal year (July 1-June 30).
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A LOOK AT SAN DIEGO COUNTY San Diego County is one of 61 local health jurisdictions (LHJs) in California. It is the second largest county in the state and the sixth largest county in the United States. The county encompasses 4,261 square miles, stretching 65 miles from north to south, 86 miles east to west, is approximately the size of Connecticut and is comprised of 18 incorporated cities and 17 unincorporated communities. The county consists of diverse populations, impacted by a large military presence and its location on the United States/Mexico border, the worlds most active international border with 40 million crossings per year. San Diego County includes a mixture of urban and rural communities from coastal beaches to mountains and desert. Much of the countys land is rural with agriculture being an important component of the countys economy. In 2009, San Diego County had an estimated population of 3,173,407 (San Diego Association of Governments [SANDAG], 2010). Table 1 shows the demographic distribution by age and gender. In 2008, approximately half of San Diego Countys population were male and half were female (data for transgender individuals is not available). Reflecting the high concentration of military in the region, males age 15 to 44 outnumber females. Thirty-five percent of the population is under the age of 25 with slightly more young males than females. There are more females than males above the age of 45 in the county. Table 1 DISTRIBUTION OF THE GENERAL POPULATION BY AGE GROUP AND GENDER COUNTY OF SAN DIEGO, 2008 Male Age (in years) <5 5-14 15-24 25-44 45-64 65+ Total # 116,403 204,228 259,148 465,639 364,270 153,560 % 7.4 13.1 16.6 29.8 23.3 9.8 Female # 112,946 203,152 224,690 441,665 383,309 202,542 1,568,304 % 7.2 13.0 14.3 28.2 24.4 12.9 100.0 Total # 229,349 407,380 483,838 907,304 747,579 356,102 3,131,552 % 7.3 13.0 15.5 29.0 23.9 11.4 100.0
1,563,248 100.0
Source: San Diego Association of Governments 2008 Population Estimates
In 2000, 313,750 persons ages 65 years or older lived in San Diego County. By 2008, the number increased to 356,102 and is expected to double by the year 2030 to 741,362. As dramatic as this increase is, it is overshadowed by the increase in persons 85 years and older in San Diego County from 36,407 in 2000 to a projected 101,260 in 2030 (County of San Diego Health and Human Services Agency, 2009).
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Table 2 shows the demographic distribution by race/ethnicity and gender of residents of San Diego as of 2008. Slightly over half of the regions total population were White (50.2%), over one quarter were Hispanics (29.9%) 14.6 percent were Asian/other (Asian, Pacific Islander, Native American and Native Alaskan) and Blacks constituted 5.3 percent of the population. Please note that in this section the ethnic and race categories used by the U.S. Census Bureau and compiled by the San Diego Association of Governments have been utilized. Throughout the rest of this document, the terminology used to refer to race and ethnicity is that which the communities of San Diego utilize in their HIV education and prevention work. For example, Hispanic is referred to as Latino and Black is referred to as African American. The greatest population growth has been seen among Hispanics, and this growth is expected to continue. During the 1990s, more than 215,000 immigrants came to San Diego County compared with 202,000 the previous decade an increase of 6.4 percent. Because more than half the county's immigrants are originally from Latin America (33% are from Asia), Latinos are certain to represent a significantly larger share of the population. They currently comprise more than a quarter of the county's population and by 2020 will account for a third of the residents (Weisberg & Sanchez, 2002). Table 2 DISTRIBUTION OF THE GENERAL POPULATION BY RACE/ETHNICITY AND GENDER COUNTY OF SAN DIEGO, 2008 Male Race/Ethnicity Hispanic White Black Asian/Other* Total # 466,812 789,194 86,768 220,474 1,563,248 % 29.9 50.5 5.6 14.1 100.0 Female # 469,081 783,952 78,230 237,041 1,568,304 % 29.9 50.0 5.0 15.1 100.0 Total # 935,893 1,573,146 164,998 457,515 3,131,552 % 29.9 50.2 5.3 14.6 100.0
*Includes Asian, Pacific Islander, Native American and Native Alaskan race/ethnicities Source: San Diego Association of Governments 2008 Population Estimates
In San Diego County, the population distribution varies significantly by region, as can be seen in Table 3. Whites make up the largest proportion of the population in the East (63.8%), North Central (62.8%), North Coastal (59.7%) and North Inland (57.2%) regions. Although Hispanics make up the largest proportion of the population in the South (53.5%) and Central regions (41.9%), the Central region is also home to the largest population of Blacks (13.4%).
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HIV and AIDS in San Diego County Compared to California and United States Nine out of ten HIV cases in San Diego (SD) County are male (90%), compare to 86 percent in California (CA) and 71 percent in the United States. There are no reliable data to compare cases for transgender individuals. Similarly for AIDS cases, nine out of ten in SD are male (92%), compare to 91 percent in CA and 81 percent in the US. There are no reliable data to compare cases for transgender individuals. In SD more Whites are infected with HIV (58%) compared to CA (48%) and US (35%); Hispanics cases are similar in SD and CA (26% and 28% respectively) and higher than the US (16%). African American cases are much lower in SD (12%) compared to CA (19%) and US (47%). Similarly for AIDS cases in SD more Whites have AIDS (61%) compare to CA (56%) and US (39%); Hispanics cases are similar in SD and CA (24% and 23% respectively) and higher than the US (19%). African American cases are much lower in SD (13%) compared to CA (18%) and US (40%). San Diego has 13,813 cumulative AIDS cases and other than San Francisco and Los Angeles, there are no other counties in the state of California that have more than 10,000 cases (the next highest is Alameda with 7, 573). (See Appendix G Gap Analysis Summary FY 2008/2009 for epidemiological data for San Diego County; US and California data can be found at www.cdc.gov or www.cdph.ca.gov)
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Table 3 DISTRIBUTION OF THE GENERAL POPULATION BY RACE/ETHNICITY AND REGION, 2008

N Coastal # % 147,224 27.2 323,438 59.7 21,781 4.0 49,027 9.1 541,470 100.0 N Central Central South % 41.9 26.8 13.4 17.8 100.0 East % 53.5 25.4 4.4 16.7 100.0 N Inland % 21.5 63.8 5.4 9.3 Total
Race/Ethnicity Hispanic White Black Asian/Other* Total
#
78,442 377,559 19,878 125,633
% 13.0 62.8 3.3 20.9
#
207,406 132,597 66,383 88,254 494,640
#
245,503 116,820 20,424 76,483 459,230
#
100,418 297,450 25,061 43,178
#
156,900 325,282 11,471 74,940 568,593
% 27.6 57.2 2.0 13.2 100.0
#
935,893 1,573,146 164,998 457,515
% 29.9 50.2 5.3 14.6
601,512 100.0
466,107 100.0
3,131,552 100.0
*Includes Asian, Pacific Islander, Native American and Native Alaskan race/ethnicities Source: San Diego Association of Governments 2008 Population Estimates
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HISTORY OF HIV EDUCATION AND PREVENTION SERVICES History of Transfer of Funding and Responsibility The County of San Diego has received state funds from the California Department of Public Health, Office of AIDS (CDPH/OA) since 1996 for the provision of HIV education and prevention (E&P) services. Prior to that date, these funds were distributed in response to statewide competitive proposals that addressed state-prioritized target populations and goals. This transfer of funding and responsibility in 1996 was made as part of Californias efforts to implement local community-based planning and delivery of HIV education and prevention services. The local planning process has allowed San Diego to better identify and prioritize appropriate target populations based on the unique characteristics of the HIV epidemic in San Diego County and to determine the most effective strategies and interventions to prevent HIV transmission and acquisition within those populations. The funding that San Diego County receives for HIV education and prevention services originates from the Centers for Disease Control and Prevention (CDC) and is administered through CDPH/OA based on a formula determined by the epidemiology of HIV in California. In the entire state of California, only the CDPH/OA and the cities of Los Angeles and San Francisco are eligible to apply directly for CDC funds for HIV prevention. The fact that the County of San Diego is not eligible to apply for CDC funds has made diminishing resources more severe in San Diego County than in other large metropolitan areas of California (see page 27, Table 5 for the history of HIV education and prevention funding). With the limited resources available, the County of San Diego is dedicated to ensuring that public funds for the prevention of HIV infection are allocated in a manner that considers best practices, cost effectiveness, accountability and consistency with community norms. The Contracting Unit of the HIV, STD and Hepatitis Branch of Public Health Services (HSHB), in conjunction with the Prevention Unit, is responsible for monitoring program effectiveness and providing technical assistance (TA) to E&P providers. In San Diego County funds are distributed through competitive procurements by regions to the South, North and Central (includes East and North Central) regions based on the prevalence and incidence of HIV and AIDS cases in each region. Services are delivered to those at highest risk to the degree that they exist in the epidemiology in each region. The County of San Diego conducts regular gap analysis to determine if there are gaps in services (see Appendix G for Gap Analysis and Summary). The contracting process follows a yearly timeline with a three-year funding cycle determined by CDPH/OA. In the third or fourth quarter of each fiscal year, which runs from July 1 through June 30, CDPH/OA sends out funding letters to local health jurisdictions (LHJs) with HIV prevention award amounts. New services are procured and/or contracts for continuing services are renewed in accordance with the County
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Purchasing and Contracting policies and procedures. Once contracts are in place, HSHB conducts annual site visits during the first or second quarter of each fiscal year. If there are any problems, contractors may receive a corrective action notice and have a follow-up site visit. Quarterly Progress Reports (QPRs) are due from contractors on the 20th day of the month following each quarter. HSHB reports progress to CDPH/OA twice a year, mid February and August. In the third or fourth quarter of each fiscal year, HSHB submits a scope of work (SOW) and budget to CDPH/OA for approval. This SOW is a compilation of all the contracted services and HSHB program objectives and budgets. HSHB, with the aid of a consultant, developed and launched the San Diego County HIV prevention website, which went live on July 1, 2008 at www.sdhivprevention.org. The site provides online access to all materials for local community planning and information for HIV E&P providers, the Prevention Group and the community at large. The information available on the website includes: contact and program information for each subcontractor, meeting schedules, minutes and materials, training calendars, a listing of community events, and recent reports. HSHB staff continue to inform providers, planning group members and community members about the site and encourage its access and use. History of Community Planning Cycles and Priority Populations With the support of the HSHB, the Prevention Group undertakes the community planning process in San Diego County. In anticipation of the shift in funding to the local planning process, the County of San Diego Board of Supervisors created the local community planning group, formerly known as the HIV Prevention Community Planning Board (Prevention Board), in 1995. At that time, the Prevention Board conducted an extensive needs assessment and planning process and developed the first three-year comprehensive plan for HIV education and prevention services. Table 4 lists the planning cycles to date: Table 4 HIV EDUCATION AND PREVENTION COMMUNITY PLANNING CYCLES Planning Cycle First Second Third Fourth Fifth Began July 1, 1996 July 1, 1999 July 1, 2004 July 1, 2007 July 1, 2010 Ended June 30, 1999 June 30, 2004 June 30, 2007 June 30, 2010 June 30, 2013
The first three-year cycle, 1996 1999, focused on the following target populations: men who have sex with men (MSM) injection drug users (IDUs) and their sexual partners high-risk youth and young adults (ages 12-24) sex industry workers
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sexually transmitted disease (STD) clinic patients Latino migrant workers Native American women
In 1995, the Prevention Board also recommended that 15 percent of the total base education and prevention funds be allocated to provide comprehensive TA and training to providers of HIV education and prevention services. In 1998, the Prevention Board conducted a comprehensive review of the epidemiology of HIV disease in San Diego County and found that there had been sufficient changes in the course of the epidemic to justify revision of the HIV prevention goals and funding priorities for the next funding cycle. These new priorities for 1999 adjusted the identified target populations to direct prevention efforts more specifically as the populations identified at highest risk for HIV infection including: MSM IDUs and their partners Individuals with recurrent STDs Within the MSM and IDU categories, funding levels were established for projects directed toward youth and people of color. The Comprehensive Plan for HIV Prevention Services for San Diego County 20042007 identified three major prevention priority populations: People living with HIV/AIDS (mandated by CDPH/OA) Persons who engage in unprotected sex, with MSM identified as a main subcategory and emphasizing persons of color, youth (ages 12 24) and MSM with STDs; any individuals with STDs and transgender individuals were identified as additional sub-categories IDUs who share syringes, with a special emphasis on populations disproportionately impacted by HIV/AIDS: MSM, people of color, and sexual partners of IDUs; additional emphasis was placed on the areas of San Diego most impacted by injection drug use In January 2007, priority behavioral risk groups (BRGs) were updated to meet recommendations from the CDPH/OA Education and Prevention 2007-2010 Program Guidance. Additional revisions to ensure BRGs were reflective of local HIV infected and affected populations were approved by the Prevention Board March 2007. The ranked HIV prevention priority BRGs outlined in the Comprehensive Plan for HIV Prevention Services for San Diego County 20072010 were as follows: HIV positive individuals at high risk Gay men and MSM, with an emphasis on African American and Latino men IDUs Women at high risk of acquiring HIV via their sexual partners, injection drug use and/or commercial sex work Sexual and/or needle-sharing partners of gay men, MSM, and IDUs
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High-risk youth, such as those at alternative schools or detention facilities with a history of chemical abuse, homelessness, or engaging in survival sex or commercial sex work Transgender individuals, with an emphasis on African American and Latino persons
History of Procurement of HIV Education and Prevention Services Due to the elimination of State general funds for HIV prevention and testing activities for the fiscal year (FY) 2009/2010 which began July 1, 2009, priorities for prevention services were further revised based on priority populations and high-risk definition from the Centers for Disease Control and Prevention (CDC) Funding Opportunity Announcement PS10-1003 Human Immunodeficiency Virus Prevention Projects For Community-Based Organizations and with input received from the Prevention Board on July 13, 2009, HIV prevention providers on July 16, 2009, HSHB staff on September 11, 2009 and a review of local epidemiological data. The current 2010-2013 ranked priority populations were established and approved on September 14, 2009 with revisions approved May 10, 2010 (see page 54). In addition to base education and prevention funds, the opportunity for additional funds was made available through competitive applications to CDPH/OA. In November 1999, CDPH/OA issued the High-Risk Initiative (HRI) Request for Applications (RFAs) to solicit proposals from LHJs for additional funding to target services for four designated populations: women, youth, people of color and MSM. In January 2000, HSHB submitted proposals for this initiative and was funded in all four categories. The following year the CDPH/OA released a RFA for a Latino HRI. Again HSHB applied and was awarded funds in this category. HRI funding ended on June 30, 2004. In 2004, CDPH/OA issued a High-Risk Behavior Change Campaign (HRBCC) RFA to conduct BCCs targeting MSM. HSHB submitted a proposal for this initiative and was awarded funding. In 2002, CDPH/OA issued a mandate requiring all LHJs to redirect 25 percent of the base education and prevention funds to programs that address prevention with HIV positive individuals (PwP). Prevention Board members, community members and representatives from community-based HIV prevention agencies were brought together to assist in the decision making process for this new mandate. PwP services began February 2003. On January 18, 2007, CDPH/OA provided LHJs with a document entitled, Education and Prevention 2007-2010 Program Guidance which was used to prepare this document as well as the Comprehensive Plan for HIV Prevention Services for San Diego County 2007-2010. Contracts for services for IDUs and their sexual partners were amended on July 1, 2007 to reflect specifications outlined in the program guidance. The contracts for MSM and PwP services ended on June 30, 2007, and new services were procured to serve high-risk HIV positives and high-risk HIV negatives based on the
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2007-2010 prioritized BRGs. Also at this time, contracts for services for IDUs and for high-risk HIV positives and high-risk negatives were merged into one contract with each of the providers. As of July 1, 2007, services for individuals who are HIV positive, HIV positive IDU, HIV negative, HIV negative IDU and at high risk for the transmission or acquisition of HIV were provided under one SOW, and a minimum of 25 percent of all HIV education and prevention funds continued to be directed to high-risk HIV positive individuals to meet the CDPH/OA mandate. To summarize, new HIV education and prevention mergers and innovations since 2000 have included the following: New High Risk Initiatives began in approximately 2000 and ended 2004. New HIV Prevention with Positive Programs (PwP) began 2002. New High Risk Behavior Change Campaigns (HRBCC) began 2004 and ended 2007. Contracts targeting MSM and PwP were merged in 2007 resulting in High Risk Positive and Negative (HRPN) contracts. HRPN contracts were merged to include injection drug users (IDUs) in 2008. History of HIV Education and Prevention Funding At the time of the approval of this plan, the next scheduled HIV prevention funding cycle (July 1, 2010 to June 30, 2013) from CDPH/OA is the three-year cycle covering the same period as this plan. However, due to the previously noted elimination of State general funds for prevention and testing activities for the FY 2009/2010, which began July 1, 2009, the CDPH/OA recognized a need to revise and refine intervention-related prevention program guidance. Initial changes were specified in a letter to LHJs from CDPH/OA dated November 4, 2009. Notably the CDPH/OA combined previously separate funding for HIV Counseling and Testing (HCT), E&P and Partner Services (PS) and requested LHJs to determine how funds would be allocated locally for each of these activities. CDPH/OA committed to undertake a comprehensive review of allowable prevention activities and related requirements to include reviewing all current CDC guidelines and recommendations and involving funded LHJ partners. To expedite provision of this interim guidance, CDPH/OA advised LHJs to maintain current prevention interventionrelated guidance. LHJs were advised they could fund prevention services in accordance with the guidelines in the Education and Prevention 2007-2010 Program Guidance. However, training previously required for implementing certain behavioral interventions was no longer available through CDPH/OA and, consequently, was no longer mandated. LHJs could elect to provide these interventions as long as other minimum requirements are met. In San Diego County, the responsibility of all training has been transferred to HSHB. Allowable prevention activities included: targeted prevention activities (TPA) for highrisk HIV negative and HIV positive persons; individual level interventions (ILI); group level interventions (GLI); comprehensive risk counseling and services (CRCS) for individuals with multiple health needs; and health communication public information
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(HCPI) for at-risk BRGs. CDPH/OA noted that the use of HCPI was discouraged as it was erroneously included in the budget guidance. It was not removed for FY 2009/2010 but it may be removed in subsequent years as it is not consistent with the CDPH/OA budget reduction implementation plan. Locally in San Diego County, HCPI has been an effective intervention and has been recommended for continuation by HSHB, the Prevention Group, advisory groups, prevention providers and partners (see benefits of HCPI in San Diego County, page 96-98). All selected activities were to be targeted to LHJ prioritized BRGs most likely to acquire or transmit HIV disease. In selecting BRGs, CDPH/OA expected utilization of recent epidemiological data, needs assessments, gap analyses, community input and/or other relevant information. All these sources were utilized and are presented in this plan. CDPH/OA further stated that community input is a significant element in developing a HIV prevention plan. As noted previously, CDPH/OA no longer requires LHJs to maintain Local Implementation Groups (LIGs) but remains supportive of this process. Procurement of HIV education and prevention services is accomplished through competitive solicitations generally using requests for proposals (RFPs). Funding has been made available through five sources since 2001 (see Table 5): CDPH/OA o E&P o HRBCC o HRI County of San Diego Other one time funds such as Tobacco Settlement funds HSHB released two RFPs in March 2007, one for HIV Prevention BCC and one for HIV Prevention with High-Risk Positives and High-Risk Negatives (HR Pos/Neg) for services in all regions of the County to begin July 1, 2007. The County of San Diego negotiated and executed contracts for 2007-2010 with a potential of two additional option years, for a total of five years. In November 2008, CDPH/OA reduced the funding by 6 percent ($1,613,216). For FY 2009/2010, CDPH/OA decreased HIV prevention funding which resulted in reductions to all HIV education and prevention direct services by 63 percent. This reduction was due to the elimination of HIV prevention funds from the State of Californias general fund. This decrease warranted a much more focused approach to HIV education and prevention. In 2000, there were as many as 16 contracts for HIV education and prevention services with 12 community-based organizations (CBOs). At the time of this writing, there are four contracts for direct services, one for behavior change campaigns and one for administrative support for providers and community planning. These contracts are with only five CBOs. For a more accurate picture of HIV education and prevention funding, see history by funding sources from 2001 to present in Table 5 and Appendix J.
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Table 5 HIV EDUCATION AND PREVENTION FUNDING SOURCES AND AMOUNTS BY FISCAL YEAR, 2001-2010
Fiscal Year 2001-2002 2002-2003 2003-2004 2004-2005 2005-2006 2006-2007 2007-2008 2008-2009 2009-2010 CDPH/OA E&P $1,372,797 $1,397,797 $1,825,326 $1,769,445 $1,725,398 $1,715,949 $1,718,862 $1,613,126 $745,340 CDPH/OA HRBCC ---------------------------$280,000 $280,000 $280,000 ---------------------------CDPH/O County of A HRI San Diego $745,000 $100,000 $795,000 $100,000 $795,000 $100,000 ---------------------------------------------------------------------------------------------------- $242, 292 Other $746,138 $659,137 ---------------------------------------------------------------Total $2,963,935 $2,952,966 $2,720,326 $2,049,445 $2,005,398 $1,995,949 $1,718,862 $1,613,126 $987, 832
FY 2008/2009 the County of San Diego received $1,613,126 HIV education and prevention funds from CDPH/OA, which was about half of the amount received in 2000 when San Diego County received $2,986,330 (not shown). FY 2009/2010 the amount received and allocated to HIV education and prevention services was reduced to $745,340. Due to delays in the state budget, the County of San Diego decided to cover the cost of services for one quarter at the level of funding prior to the budget cut (approximately $250,000). Due to cuts over the past decade, the current funding for FY 2010/2011 is anticipated to be about one quarter of the amount received in 2000 when San Diego County received $2,986,330 (not shown). See Appendix J for the distribution of HIV prevention funds for FY 2009/2010. Since 1982 in San Diego County 7,178 people have died of AIDS. In 2008, there were 67 deaths and 391 new cases reported. The medical costs associated with HIV infection are estimated at about $180,000, and lost productivity is about $750,000. An estimate in 2006 has the lifetime cost at about $620,000. Deaths and high medical costs can be prevented. HIV education and prevention services save lives and money in San Diego County, but as funding diminishes, the outlook for preventing new cases of HIV is not good.
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HIV EDUCATION AND PREVENTION COMMUNITY PLANNING PROCESS Included in this section are the flow of accountability for HIV education and prevention services (Figure 1); the community planning process; and the community planning groups function, structure (Figure 2) and membership (Table 6). The Flow of Accountability for HIV Education and Prevention Services Figure 1 shows the flow of accountability for HIV education and prevention (E&P) services from the federal government to local community based organizations (CBOs) that provide HIV education and prevention services in San Diego County. The flow of accountability for HIV education and prevention services begins with the federal government and the Centers for Disease Control and Prevention (CDC), which provide guidelines and technical assistance (TA) for the planning process and program implementation. The California Department of Public Health, Office of AIDS (CDPH/OA) provides guidance for the local planning process, administers funds, provides limited TA, monitors program implementation and reports to the CDC on HIV education and prevention activities in California. On September 9, 2009, members of the statewide California HIV/AIDS Planning Group (CHPG) approved a new model that both simplifies and expands the planning and advising structure for CDPH/OA. A web-based network which will be open to all Californians with an interest in HIV/AIDS will provide ongoing advice to CDPH/OA while prevention and care planning will be conducted in consultation with a new and smaller planning group. It is expected that these new structures will allow for both effective planning and an advising process with increased scope and reach. The mission of the new planning body, the California Planning Group (CPG), is to provide community perspectives, advice and recommendations to CDPH/OA in the planning, development, and allocation of resources for a comprehensive, client-centered continuum of prevention, care, treatment and other support services. The County of San Diego Health and Human Services Agency (HHSA) is tasked with procuring services and performs other overall contracting functions. Under the HHSA, the HIV, STD and Hepatitis Branch of Public Health Services (HSHB) plans services, develops and monitors contracts, administers funds and contracts, provides TA to contractors and reports to CDPH/OA on HIV education and prevention activities in San Diego County. The Prevention Group provides HSHB with recommendations for priority populations and assists in the development of the prevention plan. Prevention contractors implement prevention programs and report to HSHB on prevention activities through: Quarterly Progress Reports (QPRs); Local Evaluations Online (LEO); and Prevention Outcome Database (POD).
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Figure 1 FLOW OF ACCOUNTABILITY FOR HIV EDUCATION AND PREVENTION SERVICES
Local Evaluation Online (LEO) To assist with tracking of the HIV epidemic and directing HIV prevention funding to where it is needed the most, the CDC mandates the use of data collection systems. LEO is a web-based system conceptualized by CDPH/OA and developed with input from a wide variety of stakeholders including service providers from local health jurisdictions (LHJs), research scientists and program monitors, external policy makers and federal partners. Data collection permits service providers, HSHB and CDPH/OA to monitor service delivery of HIV education and prevention activities, determine service delivery gaps and improve the efficiency of HIV education and prevention services. The purposes of LEO include the following: 1) Provide CDC with required information to maintain and enhance funding relationships with state public health departments and CDC directly funded entities; 2) Ensure that CDPH/OA funded HIV prevention program activities meet contracted scope of work requirements; 3) Ensure that quality of service delivery meets minimum standards required to accomplish public health mission goals; 4) Ensure that program activities comply with state and federal legal requirements; 5) Improve local decision-making by providing immediately accessible information and feedback regarding local service delivery;
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6) Provide sufficiently detailed data to effectively inform state-level policy and funding decisions to accomplish public health mission goals; 7) Reduce administrative confusion among contracted statewide partners in fulfilling data reporting and training requirements; 8) Reduce inventory waste and inefficiencies in fulfilling supply requests, including the receipt and use of HIV rapid test kits, data collection forms and laboratory labels. Implemented for education and prevention services in May 2009, LEO standardized the data collection of all HIV prevention interventions. Due to FY 2009/2010 budget cuts and subsequent reduction of services, the Comprehensive Risk Counseling and Services (CRCS) intervention became optional for prevention providers in San Diego County as of July 1, 2009. LEO is the CDPH/OA mandated data system in which all providers enter HIV education and prevention activities. LEO was not designed to track outcome measures although the County of San Diego Purchasing and Contracting requires that all contracts have outcomes. Therefore, variables have been added to the required standardized CDPH/OA data collection tools for LEO in order to measure outcomes as required by the County of San Diego. Prevention Outcome Database (POD) The San Diego County HIV Prevention Outcome Database (POD) was developed to measure outcomes of HIV education and prevention services to answer the question How are we helping those who receive HIV education and prevention services in San Diego County? An evaluation consultant worked with HSHB and contracted providers to determine: what outcomes to measure, how to measure outcomes and what could be done to help all providers measure outcomes. To this end, standardization of outcomes was necessary so that all providers could measure outcomes. The POD organizes service delivery and outcome data into tables which are incorporated directly into required reports that contracted providers submit to HSHB four times each year. The development process for the POD was as follows: Fall 2006: Outcomes objectives training and brainstorming with providers; providers developed and reached consensus on outcome objectives June 2007: Implemented standardized process and outcome measures for all providers; July 1, 2007 contracts included these outcomes July 2007: Added variables to the standardized required data collection tools August 2007: POD created for providers to measure outcomes (first year optional); service and outcome reports available from the POD; all providers elected to utilize POD July 2008: Updated the POD and made changes to standardized outcome measures based on provider feedback; updated standardized data collection tools to measure process and outcome objectives; all providers received the POD which became required and was added to contracts effective July 1, 2008
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October 2008 and on going: POD service and outcome reports used by all providers to produce QPRs November 2008: New management reports and data validation features added to POD February 2009: POD redesigned to increase capacity for more than one year of data and produce reports for each year May 2009: Gap analysis completed using POD data June 2009: Updated POD was distributed to all providers and preparation for the FY 2009/2010 POD began June 2009: Presentation on POD during CDPH/OA at site visit at Prevention Strategies and Evaluations Committee (PS&E) August 2009: Presentation on POD to National HIV Prevention Conference January 2010: Improved functionality of POD so the viewing of data was no longer limited to quarterly (distribution of POD with this update is scheduled to take place July 2010) Ongoing: TA provided as needed
The process developed and currently underway to gather, enter, clean and report both process and outcome data and provide technical assistance is as follows: 1) Gather Data: Providers complete standardized LEO data collection tools with added POD outcome variables for all individuals served; 2) POD Entry: Providers enter the POD section of the data collection tools into the POD; 3) POD Cleaning: Providers clean the data using various lists in POD and ensure it matches what is entered into LEO; 4) QPR: Providers run POD reports and enter or paste the appropriate data directly into the QPRs; 5) QPR Review: HSHB staff review the QPRs for completeness, TA needs and accuracy; and 6) TA: HSHB and consultant, as funding permits, provide TA for the entire process (1-5 above). Outcomes being measured include referrals for testing and services. Referrals for HIV testing for those who are unaware of their status are tracked during outreach and community events and during individual and group interventions. HIV testing is tracked by provision of referral, completion of test, receipt of results and receipt of treatment. Other referrals tracked include referrals to: HIV primary care; sexually transmitted disease (STD) and hepatitis testing and treatment; detoxification and substance abuse treatment; and other non-medical services (housing, vocational education, support groups, etc.). Goals that are self-determined by the client and tracked include: increased frequency of harm reduction associated with sexual and drug use behaviors; increased frequency of condom use with main and non-main partners; STD screening and treatment; hepatitis screening, testing and vaccination; and referrals to substance abuse, mental health, and/or services for co-occurring disorders. Examples of other goals tracked include:
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obtaining information about and attending support groups enrolling in case management and/or meeting regularly with case manager having fewer public sex contacts in park, bar or bathhouse obtaining secure housing and/or secure sober living obtaining employment and/or job training working with sponsor and/or staying in outpatient substance abuse treatment testing partners for HIV attending doctor appointments following up with STD clinic taking medicines regularly
Many successes have been realized as a result of the POD. POD data was utilized to complete the gap analysis for HIV education and prevention services presented in this plan. Contracted providers have and continue to develop and report strategies to address gaps in services in each region of the County. The POD has been used to track progress in addressing the populations which were under-represented in services. The gap analysis for the most recent fiscal year (FY) showed providers were able to reduce or eliminate many of the identified gaps. Measuring objectives and sharing the results with those providing services with the expectation that gaps be addressed has resulted in reducing gaps and better targeting of services to those at highest risk for HIV in each region of San Diego County. The current funding cuts have seriously reduced HIV education and prevention services in California, and it has become increasingly more important to evaluate which interventions are most efficient and effective with each specific population in order to target limited resources. The next step for the use of POD data, as funding permits, is to conduct further analysis to assess effectiveness of each intervention overall and for each of the priority populations [men who have sex with men (MSM), injection drug users (IDUs) and partners of MSM/IDU] and for other demographic characteristics (ethnicity, gender, age and region). LEO and POD data are expected to continue to be utilized for future community and service delivery planning. The Community Planning Process Guidelines One of the main responsibilities of a local community planning group is to develop a plan for HIV education and prevention services. The plan needs to be current, evidencebased, refreshed with new information as it becomes available, tailored to the specific needs and resources of the community and widely distributed. The following is a review of the planning process as outlined in the HIV Prevention Community Planning Guide (CDC, 2003) and adapted to the community needs of San Diego County: 1. Epidemiologic Profile This describes the impact of the HIV epidemic in the jurisdiction and provides the foundation for selecting priority populations. In San Diego County, the HIV/AIDS Epidemiology Unit of Epidemiology and
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Immunization Services develops the epidemiologic profile for the current HIV/AIDS epidemic in the county. 2. Community Services Assessment This assessment describes the prevention needs of populations at risk for HIV infection, the prevention activities and interventions implemented to address these needs and service delivery gaps. The Community Services Assessment is conducted in three parts: a) Needs Assessment: The assessment determines the HIV prevention needs of the priority populations in the community and barriers to reaching those groups. In San Diego County, the needs assessment is accomplished by conducting a survey in collaboration with the HIV Health Services Planning Council (Planning Council) and by incorporating recent assessments completed for specific populations. b) Resource Inventory: This is a description of the existing resources for HIV prevention and related services. An inventory of San Diego County HIV prevention and related services is conducted by the Continuum of Care Committee (CofC) (see Appendix D for current HIV Education and Prevention Resource Inventory) c) Gap Analysis: The gap analysis compares the needs assessment and the resource inventory and then develops a description of the unmet needs. To identify service gaps in different populations and regions of the County, the PS&E Committee reviews the epidemiologic profile, needs assessment data, resource inventory, HIV counseling and testing (HCT) data and service delivery data of contracted HIV E&P service providers and other local data (see Appendix G for Gap Analysis Summary FY 2008/2009). 3. Prioritize Target Populations Prioritization focuses on a set of priority populations, identified through the epidemiologic profile and community services assessment, which require prevention efforts due to high rates of HIV infection and participation in highest-risk activities (see page 54 for a description of priority populations). 4. Appropriate Science-Based Prevention Activities and Interventions This is a set of prevention activities and interventions, based on intervention effectiveness and cultural/ethnic appropriateness, necessary to reduce transmission in priority populations. The PS&E Committee provides input on appropriate interventions. This input incorporates principles for designing HIV prevention interventions and strategies including locally developed Effective Behavioral Interventions (EBIs) and CDC Diffusion of Effective Behavioral Interventions (DEBIs), health behavior theories and models and CDPH/OA approved intervention types including Targeted Prevention Activities (TPA), Group Level Interventions (GLI), Individual Level Interventions (ILI), CRCS (optional in San Diego County as of FY 2009/2010), Partner Services (PS) and Health Communication Public Information (HCPI) activities (see Appendix B for
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description of effective HIV prevention interventions and strategies and Appendix C for health behavior theories and models). 5. Letter of Concurrence, Concurrence with Reservations or Non-concurrence This describes whether the community planning group and the health department are in agreement about the priorities set forth in the education and prevention plan. A written letter formalizes the level of agreement. The Prevention Group makes a determination to concur or not concur with the plan after it has been written (the current letter of concurrence is included on page 11). In addition to these steps, the HIV education and prevention plan may be updated as determined by the Prevention Group. Overview of Prevention Group, Committees, Advisory Groups, and Membership At the time of this writing, the Prevention Group is an advisory committee to HHSA, the Chief Administrative Officer of the County of San Diego and the County of San Diego Board of Supervisors. The Prevention Group supports broad-based community participation in planning, identifies priority needs and creates a plan that recommends how HIV education and prevention resources can most effectively target priority populations. The Prevention Group has five committees through which the required tasks are accomplished. Prevention Group members are expected to attend at least fifty percent of all Prevention Group meetings. Figure 2 provides a brief description of each committee. Each committee meets twice yearly, with the exception of the Membership and CofC Committees. The Membership Committee is an ad-hoc committee that meets as needed to accomplish specific tasks such as reviewing membership applications. The CofC Committee is a joint committee with the Planning Council, a Health Resources and Services Administration (HRSA) mandated planning group for services to people living with HIV/AIDS, and meets on a monthly basis. Prevention Group members and staff participate twice a year at the CofC Committee at which time the agenda is primarily focused on prevention. In FY 2009/2010, the Prevention Group proposed revisions to their by laws to have up to nineteen voting members and three to five members-elect with representation from a variety of service providers, community members and members of the priority populations. Three to five members are appointed by HHSA and represent Public Health Services. The County of San Diego Board of Supervisors appoints one representative from a public health program at a major university, one representative from the Planning Council and the remaining members who represent community experts in HIV prevention services and priority populations. Included in these appointments are up to three member-elect positions. Members elect immediately fill voting member seats as they become vacant. At the time this plan was approved, an action item was tabled to
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present to the Prevention Group a recommendation to the County of San Diego Board of Supervisors to transfer the supervision and administration of the Prevention Group to the Chief of the HSHB. The outcome of the action item will be clarified in future plans. In order to ensure parity, inclusion and representation, the Prevention Group actively recruits its members from communities and advisory groups that are representative of the HIV epidemic in San Diego County. This includes members of different: ages, communities of color, genders, geographical areas, sexual orientations and socioeconomic statuses Related experience working with risks associated with HIV transmission is also taken into consideration during the membership selection process. Nominations for appointed positions and applications for community positions are accepted from representatives or advocates of priority populations identified in the plan. This may include individuals who represent school districts, community colleges, universities, HIV/AIDS prevention practitioners, HCT providers, medical care service providers, social service providers, community coalitions, alcohol and drug prevention and treatment service providers, mental health services providers, criminal justice system practitioners, behavioral and social science practitioners including epidemiology, evaluation and health planning, HIV funding agencies and/or corporate entities. Each year the Prevention Group conducts a membership survey to review and assess the demographics of the group, which is in turn used to inform the process of selecting new members. Details of the 2009 membership survey can be found in Table 6.
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Figure 2 HIV EDUCATION AND PREVENTION COMMUNITY PLANNING GROUP STRUCTURE
County of San Diego Board of Supervisors
County of San Diego Health and Human Services Agency (HHSA) HIV, STD and Hepatitis Branch of Public Health Services (HSHB)
County of San Diego HIV Prevention Community Planning Group (Prevention Group)
Steering Committee Directs the Prevention Group by setting meeting agendas, tracking member attendance and ensuring its operation is in compliance with bylaws, CDPH/OA requirements and CDC guidelines.
Coalition of Latino AIDS Service Providers (CLASP) Advises the Prevention Group on issues relating to prevention services for the Latino(a) community.
C O M M I T T E E S
Epidemiology and Target Populations Committee (E&TP) Develops statistical and graphic representations of the HIV/AIDS epidemiologic data in San Diego County to help identify priority populations to target for HIV prevention activities.
HIV CARE Partnership Advises the Prevention Group on issues relating to prevention services for women, children, and families.
A D V I S O R Y G R O U P S
Prevention Strategies and Evaluations Committee (PS&E) Reviews the current literature and data for intervention strategies and evaluation methods, conducts the gap analysis and makes recommendations to improve the effectiveness of local prevention activities.
Kemet Coalition Advises the Prevention Group on Issues relating to prevention services for the African American community with various subcommittees including the Faith-Based Working Group (FBWG).
Continuum of Care Committee (CofC) A joint committee of the Prevention Group and the Planning Council that addresses the entire continuum of HIV services including care and treatment, counseling and testing, prevention, surveillance, research and services for STD and hepatitis, alcohol and drug, mental health and housing to high-risk individuals.
Transgender Advocacy & Services Center (TASC) Advises the Prevention Group on issues relating to prevention services for transgender individuals.
Membership Committee Recruits members, reviews applications for community seats and recommends new members based on parity, inclusion and representation for approval by the Prevention Group and the Board of Supervisors.
Youth Council (YC) Advises the Prevention Group on issues relating to HIV prevention services for youth.
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Table 6 SAN DIEGO COUNTY HIV PREVENTION COMMUNITY PLANNING GROUP 2009 MEMBERSHIP SURVEY
n = 24; total membership = 28
Category
15-24 years 25-34 years 35-44 years 45-54 years 55+ years Heterosexual Gay Lesbian Bisexual Other Under $10, 000 $10,000-$19,999 $20,000-$29,999 $30,000-$49,999 $50,000 or more Male Female Transgender, M-F Transgender, F-M Other African American/Black (non-Hispanic) American Indian/Alaska Native Asian/Pacific Islander Caucasian/White (non-Hispanic) Hispanic/Latino(a) Other Less than high school Some high school (no GED) High school graduate (or GED) Some college Associate degree (2 years) College graduate (Bachelors Degree) Post-graduate study Central East County North Central North Coastal North Inland South Bay
%
8.3 25.0 25.0 20.8 20.8 33.3 37.5 16.7 12.5 0.0 4.2 8.3 0.0 33.3 54.2 50.0 41.7 4.2 4.2 0.0 11.1 3.7 14.8 37.0 22.2 11.1 0.0 0.0 0.0 13.0 8.7 30.4 47.8 79.2 12.5 4.2 0.0 0.0 4.2
n
2 6 6 5 5 8 9 4 3 0 1 2 0 8 13 12 10 1 1 0 3 1 4 10 6 3 0 0 0 3 2 7 11 19 3 1 0 0 1
Age
Sexual Orientation
Yearly Income
Gender Identity
Race/Ethnicity
Level of Education
Location of Residence
Category
HIV Status HIV negative HIV positive AIDS diagnosis Unknown
%
75.0 12.5 8.3 8.3
n
18 3 2 2
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Table 6 (Continued) SAN DIEGO COUNTY HIV PREVENTION COMMUNITY PLANNING GROUP 2009 MEMBERSHIP SURVEY
n = 24; total membership = 28
Employment Affiliations*
Alcohol and substance abuse agency Business or other corporate organization Community clinic Corrections agency Developmental disability agency Education agency Foundation or philanthropic organization Gay and lesbian advocacy/services agency HIV/AIDS advocacy/services agency Hospital Local government agency Mental health agency Minority advocacy/services agency National organization Not-for-profit community-based agency Professional association Public health clinic Religious community Research agency Social services agency State association State government agency STD program TB program Transgender advocacy/services agency University or college Women advocacy/services agency Youth services agency Other
%*
33.3 12.5 37.5 4.2 4.2 29.2 4.2 16.7 41.7 12.5 16.7 12.5 20.8 4.2 37.5 8.3 16.7 8.3 12.5 16.7 4.2 4.2 25.0 8.3 16.7 16.7 4.2 20.8 12.5
n
8 3 9 1 1 7 1 4 10 3 4 3 5 1 9 2 4 2 3 4 1 1 6 2 4 4 1 5 3
Applicable knowledge*
Alcohol and/or substance abuse Behavioral and social science research Bisexuals Case management Children (under 15) Epidemiology Evaluation research Gay men/men who have sex with men Group living situations Health planning Hearing impaired persons Homeless/transient persons Immigrant populations Injection drug use Lesbians Mental health or co-occurring disorders Migrant persons Monolingual non-English speaking Peer education Persons in the criminal justice system Persons who pierce or tattoo Persons with hemophilia Persons with HIV/AIDS Persons engaged in high-risk behaviors for HIV/AIDS Persons with other disabilities Persons with STDs Religious or spiritual community Sex industry workers Sexual partners of persons at high risk for HIV Specific racial/ethnic population Street outreach Transgender persons Visually impaired persons Women at risk Youth/young adults (15-24) Other
%*
70.8 50.0 45.8 45.8 54.2 37.5 33.3 70.8 50.0 33.3 20.8 62.5 62.5 58.3 58.3 50.0 50.0 41.7 45.8 37.5 33.3 8.3 91.7 87.5 16.7 75.0 29.2 50.0 66.7 33.3 54.2 45.8 16.7 45.8 75.0 8.3
n
17 12 11 11 13 9 8 17 12 8 5 15 15 14 14 12 12 10 11 9 8 2 22 21 4 18 7 12 16 8 13 11 4 11 18 2
Note: These data reflect the results of the 24 anonymous surveys that were received as of December 23, 2009. It does not reflect new appointments, resignations, or members that did not complete a survey or left questions unanswered. Source: 2009 HIV Prevention Group Membership Survey, County of San Diego *Percentages base on multiple responses
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There are five advisory groups which are designated in an advisory capacity to make recommendations to the Prevention Group on HIV prevention issues specific to the populations they represent and serve. October 2007, the Prevention Group by laws were revised to clarify the roles and responsibilities of the groups designated in an advisory capacity. At the request of a group and upon a vote of the Prevention Group, the only requirement for advisory groups is to maintain one active Prevention Group member. The longest standing advisory group is the Youth Council, which has been advising the Prevention Group since 2003. In May 2008, the following groups were designated in an advisory capacity: HIV CARE Partnership, Coalition of Latino AIDS Service providers (CLASP) and the Kemet Coalition. In July 2009, the Transgender Advocacy and Services Center (TASC) became an advisory group. The evolving Prevention Group structure, with the support of advisory groups working in collaboration with HSHB staff and Prevention Group members, has resulted in many benefits including: Communities that are overrepresented in the HIV/AIDS epidemiology have a consistent voice in the community planning process Advisory groups provide reports at Prevention Group meetings to inform the community of important prevention related activities Recruitment of Prevention Group members is targeted to all affected populations through advisory group participation HSHB staff attend advisory group meetings to seek guidance on HIV prevention issues specific to the populations each group represents and serves
The mission and a brief history of each of these groups follows: Coalition of Latino AIDS Service Providers (CLASP): For more information, please visit www.projectclasp.org. The Coalition of Latino AIDS Service Providers (CLASP), was formed in June of 2002 by a group of concerned HIV prevention providers committed to strengthening the collaboration among the agencies providing HIV/AIDS services to Latino/as in San Diego County. Their mission is to bring together all agencies in San Diego County for collaboration, advocacy, education and information in order to provide quality and coordinated services to the HIV/AIDS Latino community. CLASP was originally composed of eleven agencies/organizations and now consists of over fifteen community organizations within San Diego County and the Tijuana region. CLASP provides an environment for community representatives to discuss and address barriers to reaching and serving HIV positive Latino/as. As a cooperative, CLASP has continued to play an important role in the community through collaboration and education. CLASP has been an advocate for quality HIV services for Latino/as, whether it be fighting for culturally sensitive services for Latinos, or protesting budget cuts. On October 15, 2008, CLASP hosted its first-annual National Latino AIDS Awareness Day (NLAAD), an event that included education, testimonials, free food and free HIV testing. The NLAAD event was centrally located at the Sherman Heights Community Center with over 300 people in attendance. CLASP has continued
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to host NLAAD yearly as an example of its collective effort to educate and provide quality care to under-served Latino/as. HIV CARE Partnership of San Diego County: For more information, please visit www.ucsdmcap.org. The San Diego County HIV CARE Partnership is a collaboration of consumers, providers and community members that empowers consumers, shares resources, educates the community, advocates for public policy and plans services for women, children, youth and families living with and affected by HIV/AIDS. Founded in 1995, The HIV CARE Partnership serves as the Ryan White Part D network, organizing and providing comprehensive and coordinated HIV services for women, children, youth and families. The HIV CARE Partnership also serves as an advisory committee to the Planning Council. The HIV CARE Partnership works to increase access to HIV care and prevention services including: testing, outreach, primary HIV care, HIV specialty care, obstetrics, adherence counseling, case management, health education, nutrition, mental health care, substance abuse services, educational advocacy, support groups, housing, transportation and clinical research. The HIV CARE Partnership meets monthly to discuss issues facing consumers, assess and address gaps and educate providers. Working collaboratively across health and social service agencies, the HIV CARE Partnership provides an annual educational HIV conference for women, promotes family development activities, support groups and conducts collaborative outreach activities. The meetings are open to anyone interested and actively create opportunities for consumers and promotes leadership development. The HIV CARE Partnership is organized by the UCSD Mother-Child-Adolescent HIV Program and involves more than 15 agencies. The current goals for the HIV CARE Partnership include the following: provide and coordinate high quality, cost efficient HIV primary medical care and responsive support services that link women, children and adolescents to HIV care; identify HIV positive patients who are not in care and link them to medical care; increase the number of women and youth ages 13-24 receiving HIV tests and HIV care; educate clients and assist them to develop and to maintain behaviors that will prevent the transmission of HIV and promote their health; eliminate mother to child HIV transmission by increasing HIV testing and providing comprehensive prenatal care, HIV care and perinatal HIV risk reduction interventions for HIV infected pregnant women and their infants; improve access to information on clinical research, enrollment into and retention of children, adolescents, women and men on clinical trials; and increase the involvement of consumers in the planning, delivery and evaluation of services for HIV infected children, adolescents, women and families. Kemet Coalition: For more information, please visit www.kemetcoalition.org. The Kemet Coalition (Kemet) is a not for profit, non-governmental organization with a mission to stop the spread of HIV/AIDS in the African American community by building the capacity of HIV/AIDS service providers that serve people of African descent in San Diego County.
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The Kemet Coalition empowers individuals and organizations to actively participate in advocacy and policy work related to HIV/AIDS, increase the number of African American healthcare professionals who are knowledgeable about HIV/AIDS, and collaborate with African-centered researchers to create culturally appropriate prevention interventions. Kemet began in 2003 following a state summit which was the culmination of planning for the regions to begin their groundwork for organizing and becoming proactive with HIV/AIDS issues in their African American constituencies. Kemet is committed to leveraging strengths and opportunities and proactively addressing challenges to achieve its vision and mission in a manner that is consistent with its values. Kemets vision is for a higher quality of life for people of African descent living with HIV/AIDS. Their mission is to provide a platform to enhance communication and collaboration among HIV/AIDS service providers serving people of African descent in San Diego County. To value and achieve their vision and mission, the Kemet Coalition is committed to the following values: Collaboration; Cooperation; Commitment; Mutual Respect; Assertive Leadership; Working with diverse populations; Empathy; Excellence; Communication; Integrity; Responsibility and Accountability to the Community; Trust; Teamwork and Open-mindedness In support of their commitment, Kemet has established specific strategic goals to support the mission in the following areas: Education, Advocacy and Policy - improve the collective capacity of people of African descent to succeed in advocacy, community-based research and policy work relating to HIV/AID issues through educational efforts; Human Resource Development Increase the number of African American health paraprofessionals and professionals who are knowledgeable and informed about HIV/AIDS and related issues; Organizational Capacity Build capacity and provide technical assistance to enhance collaborative prevention efforts with organizations serving people of African descent in San Diego County; and Research Develop a task force of experts and scholars in African-centered thought and HIV/AIDS to guide culturally appropriate HIV-related research that would translate into programs and materials. The Faith-Based Working Group (FBWG) is a subcommittee of Kemet and has a unique history in that it was created to assist in meeting a requirement from the Office of Performance Review (OPR) of HRSA. Its mission is to engage and sustain relationships with the faith-based community in order to openly discuss, educate and actively address the disproportionate impact of HIV/AIDS on people of African descent in San Diego County. In 2006, the County of San Diego was selected to develop improvement strategies for Ryan White care and treatment services to address unmet need, specifically for people living with HIV/AIDS who know they are HIV positive but are not receiving HIV
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primary medical care. OPR, HSHB and the Planning Council worked together to gather information on unmet need for people living with HIV/AIDS overall, for African Americans and for women. In March 2007, the CofC Committee and Kemet agreed to assist in developing and implementing the OPR action plan to address unmet need among African Americans. Finalized in April 2007, this action plan included three goals: 1) engage the faith-based community, 2) administer and enhance targeted outreach efforts and 3) strengthen and develop linkages, including substance abuse, mental health, housing, and social services. The FBWG convened in September 2007 as a subcommittee of the CofC Committee to engage African-American faith-based stakeholders in addressing disparities in access to health care by African Americans. Objectives assigned and met included assisting faith-based organizations to incorporate HIV/AIDS in their health and prevention ministries and consider opportunities to provide outreach and advocacy. The FBWG coordinated TA to members to prepare them for more active involvement in service delivery. The overall outcome was increased faith-based community involvement in establishing or expanding HIV ministries and preparing infrastructures for delivery of services to communities of color. The FBWG assisted in the development and continuing implementation of the African American Gay Men/MSM HIV Prevention and Counseling and Testing Action Plan for San Diego County (AAAP) to increase access to HCT and HIV education and prevention services by African Americans (see page 57 for details on AAAP). In January 2009, the FBWG subsequently transitioned to become a committee of Kemet to assure sustainability of the group and the continued benefits of participation from the faith-based community. Transgender Advocacy and Services Center (TASC): For more information, please visit www.thecentersd.org/trans.php. The Transgender Task Force was established as an ad hoc subcommittee of the Prevention Group in November 2003. The task force developed a transgender literature review and resource guide. In March 2005, the task force was designated by the Prevention Group in an advisory capacity. The name of the advisory committee was changed June 2005 to the Trans Action Advisory Group (TAAG). In 2007 the advisory group developed a transgender HIV risk assessment and provided input concerning the barriers transgender individuals experience when attempting to access HIV education and prevention services in San Diego County as well as strategies to address these barriers. The barriers and strategies are listed on page 69. The Transgender Advocacy and Services Center (TASC), formerly the Transgender Community Coalition, has been active in providing leadership and advocacy for the transgender community since 2004. In 2009, TAAG members and the Steering Committee determined that merging TAAG into TASC would aid in more fully engaging the community to address the unique HIV education and prevention needs of transgender individuals. At least once a quarter and as the need arises, HSHB staff attend TASC meetings when HIV prevention for the transgender community is an agenda item.
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Youth Council (YC): For more information, please visit www.ucsdmcap.org/youth/yc.htm. The Youth Council is a group of diverse youth and youth service providers who meet to talk about health and social problems that concern todays youth, specifically HIV/AIDS and sexually transmitted infections. Their mission states: We, youth advocates, speak out for young people who are HIV positive or at risk for HIV infection. We help to connect them to the youth friendly services they need to maintain healthy lifestyles. We plan conferences, educational programs, and social events. We, the youth, have a voice. Stand up and be heard! Since 1997, the Youth Council has collaborated with various youth service providers to develop youth driven projects to educate other youth about HIV/AIDS. In the early beginnings, the Youth Council reviewed grants for San Diego Countys youth mini grants which focused on HIV prevention for youth. In 2003, the Youth Council became an official advisory group to the Prevention Group. Some past accomplishments include youth conferences and World AIDS Day events at various high schools in San Diego County. The group also participates in HIV Testing Day activities as well as the San Diego AIDS Walk. Recently, the Youth Council developed three audio public service announcements which are available in English and Spanish. The Youth Council is a safe place for youth ages 13 to 24 to develop their leadership and organization skills through mentoring that is provided by a supportive group of youth service providers. During monthly meetings, guest speakers present on various challenges that affect todays youth. The meetings also serve as a place where community members network and share information about current resources available for youth. As a result, members participate in on-going community events and health fairs.
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HIV Prevention Group Community Planning Process Evaluation The community planning process is not possible without community participation, the result of which is the HIV education and prevention plan. The last component of the planning process is to evaluate the process itself. The goals for the community planning process are listed below in table 7. Surveys were distributed to the 28 Prevention Group members on April 12, 2010. Members were asked to indicate to what degree the felt each goal was met. These data reflect the results of the 21 surveys that were received as of May 3, 2010 (it does not reflect members that did not complete a survey). Table 7 SAN DIEGO COUNTY HIV PREVENTION COMMUNITY PLANNING GROUP 2010 COMMUNITY PLANNING PROCESS EVALUATION OF GOALS
n =21; total membership = 28 GOAL ONE Community planning supports broad-based community participation in HIV prevention planning. The Prevention Group implemented an open recruitment process for membership (outreach, nominations, and selection). Prevention Group membership is representative of the diversity of populations most at risk for HIV infection in San Diego County. The Prevention Group includes key professional expertise and representation from key governmental and non-governmental agencies. The Prevention Group fosters a community planning process that encourages inclusion and parity among community planning members. GOAL TWO Community planning identifies priority HIV prevention needs (a set of priority target populations and interventions for each identified target population) in each jurisdiction. The process to determine the jurisdictions highest priority prevention needs that are population-specific was logical and evidence-based. Prioritized target populations are based on an epidemiologic profile and a community services assessment. Prevention interventions for identified priority target populations are based on behavioral and social science, outcome effectiveness, and/or have been adequately tested with intended target populations for cultural appropriateness, relevance, and acceptability. GOAL THREE Community planning ensures that HIV prevention resources target priority populations and interventions set forth in the HIV education and prevention plan. There is a direct relationship between the HIV Education and Prevention Plan and the HIV education and prevention services in San Diego County. Not Met Somewhat Met Met
0 0 0 0
Not Met
0 0 1 1
3 2 1 2
Somewhat Met
3 8 1 5
15 11 18 13
Met
0 0 0
1 1 1
2 1 2
7 8 10
11 11 8
Not Met
Somewhat Met
Met
12
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Prevention Group members were then asked to what degree they felt the components of the community planning process outlined by the CDC were completed. Specific components of the community planning process are listed in Table 8 below. These data reflect the results of the 21 surveys that were received as of May 3, 2010 (it does not reflect members that did not complete a survey).
Table 8 COUNTY OF SAN DIEGO HIV PREVENTION COMMUNITY PLANNING GROUP 2010 COMMUNITY PLANNING PROCESS EVALUATION OF COMPONENTS
n =21; total membership = 28 Community Planning Process Components Epidemiologic profile The epidemiologic profile described the impact of the HIV epidemic in San Diego County and provided a foundation for prioritizing target populations. Needs assessment The assessment determined the HIV prevention needs of the priority populations in San Diego County and barriers in reaching those groups. Resource Inventory This described the existing resources for HIV prevention and related services in San Diego County. Gap analysis The gap analysis compared the needs assessment and the resource inventory and developed a description of the unmet needs and identified service gaps in different populations and regions of San Diego County. Prioritize target populations Prioritization focused on a set of target populations (identified through the epidemiologic profile, needs assessment, resource inventory and gap analysis) that require prevention efforts due to high rates of HIV infection and high incidence of risky behaviors. Appropriate Prevention Activities/Interventions Input for activities/interventions necessary to reduce transmission in prioritized target populations were based on intervention effectiveness and cultural/ethnic appropriateness. HIV Education and Prevention Plan Produce an accurate plan that is relevant to the populations at risk for transmitting or acquiring HIV in San Diego County. Not Met Somewhat Met Met
0 0 0 0
0 1 1 0
1 1 0 2
4 5 6 4
16 14 14 15
13
0 0
0 1
5 2
6 5
10 13
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Additional Community Planning Data Sources Substance Abuse, Prevention and Treatment (SAPT) HIV capacity-building projects to address substance use as a risk factor for HIV for FY 2008/2009, ending June 30, 2009, were coordinated by HSHB with funding from the County of San Diego Alcohol and Drugs Services (ADS). Complete reports are available at www.sdhivprevention.com. Summaries of the following three reports are described below: Methamphetamine and HIV in San Diego County: A Provider and Community Assessment San Diego County HIV Risk Behavior and HIV Education and Prevention Services San Diego County Lesbian, Gay, Bisexual and Transgender (LGBT) Community Substance Abuse and HIV Community Readiness Assessment (CRA)
Methamphetamine and HIV in San Diego County: A Provider and Community Assessment The San Diego Association of Governments (SANDAG) updated and expanded a 2007 report with data collected in the 2008 San Diego County Health Services Provider Survey and focus groups conducted in 2009 with HIV E&P providers. The complete report, Methamphetamine and HIV in San Diego County: A Provider and Community Assessment, describes recent trends related to the needs of providers and drug users affected by meth. One hundred twenty-five providers completed the 2008 San Diego County Health Services Provider Survey. Of the survey respondents, 62 reported providing services to meth users and the data are presented in the final report. Four focus groups with all HIV E&P provider staff members (29) regarding working with individuals who use meth were conducted May 2009. The purpose of these groups was to learn what trends providers had observed over the preceding two years among meth-using clients. These included general trends in meth use, connection between meth and sexual behavior, successful strategies used to help clients reduce or stop using meth, and challenges staff have faced in treating clients. Focus group members were also asked what limitations they faced in providing services due to the uncertain financial climate and what key points from the focus groups needed the most urgent attention. Findings and recommendations from the focus groups are included in the final report. Caution should be used when making generalizations about the comparisons made since participants in both data collection efforts were part of different convenience samples of service provider staff. This project also included an updated Meth Strategies Organization Chart (formerly referred to as the Meth Map), which is a visual depiction of all activities that address harms related to meth in San Diego County (see Appendix E) and an associated Meth Resources Directory (see Appendix F). Findings and recommendations included in the report were: continue to train those providing substance abuse treatment on how to candidly talk about sex and risk-taking behaviors with meth users. Professionals who
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serve meth-using clients must have the most up-to-date information and training available. It would also be advantageous to conduct focus groups with substance abuse treatment provider staff as well as active and recovering meth users to obtain data about their perceptions of risk associated with meth use and strategies which may help address their needs. San Diego County HIV Risk Behavior and HIV Education and Prevention Services SANDAG updated and expanded the report San Diego County HIV Health Services Assessment: Summary of Risk and Prevention Services with HIV prevention service provider data collected in 2008. This report included a summary of provider data related to HIV education and prevention services and data for high-risk behaviors reported by HIV positive individuals in San Diego County. The San Diego County 2008 Health Services Survey for People Living with HIV/AIDS was distributed through healthcare providers and at other locations that serve people living with HIV/AIDS. Of the 840 surveys completed, 477 respondents were identified as at high risk for transmitting HIV (the final report described how this determination was made). A provider survey was completed by 125 individuals working at agencies across San Diego County. Of the respondents, 54 individuals reported providing HIV education and prevention services at 39 agencies. Surveys were conducted utilizing a convenience sample of providers and people living with HIV/AIDS in San Diego County; therefore, the findings may not generalize equally well to all segments of the population. Some variables were answered by only a small number of respondents, making analysis difficult. Recommendations were developed based on the findings and focused on specific education and prevention efforts, where to target these efforts and on additional data needed. HIV prevention specific recommendations cited include prevention messaging, population and regional differences related to risky behavior, and the use of social marketing in multiple modalities to disseminate information to meet the needs of targeted populations. Concerning future data analyses, additional examination of how different risk groups varied would be beneficial in offering direction for future HIV education and prevention services. San Diego County Lesbian, Gay, Bisexual and Transgender (LGBT) Community Substance Abuse and HIV Community Readiness Assessment (CRA) A community readiness assessment to address substance use as a risk factor for HIV in the LGBT community was conducted from May to June 2009. The assessment included key informant interviews with 40 LGBT community leaders and a survey of 393 San Diego LGBT community members. This was the first survey of its kind in the San Diego County LGBT community. The San Diego LGBT Substance Abuse and HIV Task Force was established to guide the assessment process with representation from County of San Diego and community48
based organizations. The task force met monthly from March through June 2009, and members also provided input to the assessment process and instrument via email. At a full meeting of the task force, 69 community leaders in the San Diego LGBT community were identified as potential key informants. An effort was made to ensure representation from a full spectrum of LGBT community sectors, including: businesses/business owners, bisexual, community organizations and events, education, faith-based community, family, LGBT political leaders, media, seniors, transgender, treatment, youth and public and behavioral health. The key informant interview survey instrument included the following topics: general concern about the issue in the community, community knowledge, community efforts, leadership, community motivation, resources for prevention efforts, prevention strategies and demographics. As a companion to the key informant interviews, a community survey was conducted to gather data regarding LGBT community members knowledge and attitudes towards alcohol and drug use as a risk factor for HIV in the community and to gather feedback on particular prevention and risk reduction strategies. The survey instrument was developed using content from the key informant interview survey instrument as well as content generated by the task force. The community survey included the following topics: preferred news sources, community connectedness, awareness and concerns of alcohol/drugs and HIV, support for business practices, community readiness, prevention feedback, and demographic information. The community survey was available in English and Spanish. Both surveys utilized a non-probability sampling method. Given the difficulty in sampling the target population, both researchers and the task force deemed probability sampling as too costly and beyond the scope of the project. Thus, confidence intervals could not be calculated for these data. Respondents for these surveys were selected from among those who volunteered to participate and may not represent those of all San Diego LGBT leaders or community members. The online survey was available to complete for 34 days during May and June 2009. Of the 393 respondents who completed the survey, 367 were completed in English and 26 in Spanish, 186 were self-administered and 207 were completed by individuals online. Additional information on the development of the LGBT survey and data collected through the key informant interviews and the implementation, and distribution of the LGBT survey are available in the final report. This pilot study was an important and ambitious effort to begin to understand and address substance use as a risk factor for HIV in the San Diego LGBT community. Due to funding and time constraints, it was not feasible to attain a large enough sample size to effectively assess any relationships between variables. Although it was a challenge to engage multiple stakeholders in the planning process it was also of great benefit in the development of new partnerships between organizations from different sectors including research and HIV and substance abuse prevention. In addition, new partners in prevention efforts are now possible with the dozens of community leaders and organizations. The final report includes valuable information about what LGBT community members think and perceive as well as what they support and do not support as far as how to address substance use as a risk factor for HIV. This pilot study
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merits follow up with further research. Questions to ask for future research can be found in the final report. Further studies should attempt to use a random sample, which would generate data representative of the community as a whole, and garner a large enough sample to drill down and gain a deeper understanding of the opinions and motivations of various subgroups within the LGBT community. A summary of actionable findings can be found on page 78 in the Future Directions section of this plan.
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The Step by Step HIV Education and Prevention Community Planning Process HSHB staff began the process of planning and compiling information for the 2010-2013 HIV education and prevention plan in August 2007. Table 9 below describes the data that was collected, reviewed, and incorporated, when appropriate, into local action plans and this current HIV education and prevention plan. Also included in the table are the committees and community groups where information was presented and input was solicited. Table 9 STEP BY STEP HIV EDUCATION AND PREVENTION COMMUNITY PLANNING PROCESS SUMMARY
Legend: CARE HIV CARE Partnership CofC Continuum of Care Committee E&TP Epidemiology and Target Populations Committee FBWG Faith-Based Working Group HSHB - HIV, STD, and Hepatitis Branch of Public Health Services NCSPG North County Strategy Planning Group Prevention Group HIV Prevention Community Planning Group PS&E Prevention Strategies and Evaluations Committee TAAG Trans Action Advisory Group TPWG Target Populations Working Group SBSPT South Bay Strategy Planning Team YC Youth Council Resource Inventory Resource Inventory for HIV Education and Prevention Services Meth Organizational Chart and Resource Inventory Gap Analysis and Regional Data Distribution E&P/NIGHT Service Delivery Data Date 08/11/08 10/24/08 09/04/09 Date 08/22/08 09/10/08 10/24/08 07/25/08 08/08/08 Gap Analysis Data Table FY 2007/2008 08/11/08 08/22/08 09/10/08 10/13/08 Gap Analysis Data Table FY 2008/2009 Prioritize Priority Populations Ranked Priority Populations; Definition of Highest Risk 08/10/09 Date 09/9/09 Location PS&E E&TP Meth Strike Force Location SBSPT NCSPG E&TP SBSPT SBSPT PS&E E&TP; SBSPT NCSPG PS&E PS&E Location Prevention Group
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Table 9 (Continued) STEP BY STEP HIV EDUCATION AND PREVENTION COMMUNITY PLANNING PROCESS SUMMARY
Effectiveness of Interventions E&P Service Delivery Data FY 2007/2008 E&P Service Delivery Data FY 2008/2009 2008 Health Services Needs Assessment and HIV Prevention Services to Address HIV Risk Recommendations Review Recommendations for HIV Positive Review Recommendations/Barriers for MSM, IDU and their Partners Review Recommendations for High-risk Women Review Recommendations for High-risk Youth Review Recommendations for Transgender Strategies to Address Barriers for African Americans for Youth for HIV Positive Individuals for Women for Latinos Data for Action Plans AIDS in Blacks Report AIDS in Hispanics Report Region Briefs: HIV/AIDS, HCT Data (2002-2007) HIV & AIDS Prevalence Data Evaluating Local Interventions Data GIS Maps for African Americans GIS Maps for Hispanics Draft 2010-2013 HIV Education and Prevention Plan Incorporate Action Plan Goals and Objectives Date 10/13/08 03/09/09 02/08/10 08/08/08 10/20/08 02/08/10 Date 11/14/08 01/07/10 11/17/08 12/10/08 01/21/08 Date 03/04/10 03/09/10 03/12/10 03/15/10 03/17/10 Date 08/10/07 05/23/08 08/22/08 08/22/08 08/22/08 08/10/07 08/22/08 09/10/08 Date 02/8/10 Location PS&E Prevention Group PS&E CofC CARE PS&E Location CofC TPWG CARE YC TAAG Location FBWG YC CofC CARE CLASP Location E&TP E&TP E&TP E&TP E&TP CofC; E&TP E&TP; SBSPT NCSPG Location PS&E All Prevention Group Committees and Advisory Groups Location Steering Committee Prevention Group
Draft HIV Education and Prevention Plan Distributed for Initial Review
03/12/10
Final 2010-2013 HIV Education and Prevention Plan All HSHB and Community Input Incorporated Final Plan Approved at Prevention Group
Date 04/12/10 05/10/10
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HIV EDUCATION AND PREVENTION PRIORITY POPULATIONS AND DEFINITION OF HIGHEST-RISK INDIVIDUALS AND ACTIVITIES Priority Populations and Definitions of Highest Risk The community planning process requires meaningful community involvement in prevention planning to help target resources to those communities at highest risk for HIV transmission and acquisition (CDC, 2003). Previous sections have outlined the community planning process that the San Diego County HIV Prevention Community Planning Group (Prevention Group) undertook between August 2007 and May 2010. This section describes one of the outcomes of this process and includes a description of the priority populations that were established and ranked as HIV education and prevention priorities for San Diego County. Strategies to address the barriers to accessing prevention services common to all those engaged in the highest-risk activities, and communities that were identified as having specific needs within the priority populations including (in alphabetical order) African American, HIV positive, Latino, transgender, women and youth populations are presented in the next section. HIV Prevention Priority Populations One of the most important activities of the community planning process is to identify and prioritize populations to target HIV education and prevention (E&P) efforts. The outcome of this process guides the prioritization of limited resources. July 2009, all California State general funds previously allocated to HIV education and prevention services were eliminated. At that time, all funds available to the HIV, STD and Hepatitis Branch of Public Health Services (HSHB) administered through the California Department of Public Health, Office of AIDS (CDPH/OA) originated from the Centers for Disease Control and Prevention (CDC). The result was a 63 percent reduction in all direct HIV education and prevention services. With this drastic cut in funding, it was a necessary step in the community planning process to prioritize education and prevention efforts to populations engaged in the highest-risk activities. Also to stay in alignment with the origin of the funds for education and prevention services from the CDC, the decision was made for the purpose of planning to change the language used to refer to target populations from behavioral risk groups (BRGs; the term used by CDPH/OA in 2007 guidance) to priority populations (the term used by CDC in 2010 funding announcement for prevention services). The needs assessment, resource inventory and gap analysis were collaboratively completed by HSHB, Prevention Group, and HIV Health Services Planning Council (Planning Council) and their committees. The epidemiologic profile was developed by the Epidemiology Section of the County of San Diego Epidemiology and Immunization Services (EIS) for use by both the Prevention Group and the Planning Council. In September 2009, the Prevention Group approved and ranked three priority populations for HIV prevention services for San Diego County. These priorities were based on the needs assessment, resource inventory, gap analysis, epidemiologic profile, and input received from the Prevention Group and prevention providers July 2009 and HSHB staff
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September 2009. The ranked HIV prevention priority populations are shown in Table 10 and were approved by the Prevention Group September 14, 2009. Additions to the language to include men who have sex with both men and women as well as all ages, genders, races and ethnicities was approved on May 10, 2010.
Table 10 SAN DIEGO COUNTY RANKED HIV EDUCATION AND PREVENTION PRIORITY POPULATIONS, 2010-2013 1. Men who have sex with men (MSM; including men who also have sex with women and men of all ages, genders, races and ethnicities) 2. Injection drug users (IDUs; including IDUs of all ages, genders, races and ethnicities) 3. Partners of MSM and IDUs (including partners of all ages, genders, races and ethnicities) Although the priorities approved by the Prevention Group are focused on MSM, IDU and their partners of all ages, genders, races and ethnicities, this plan also recognizes that women, youth and transgender individuals are important populations at risk for HIV infection. While the limited funds available through this plan are not currently allocated for specific prevention efforts in these populations, HSHB, the Prevention Group and advisory groups acknowledge the need to prevent HIV in all populations at risk. Additional funds are needed in San Diego County for HIV education and prevention efforts that are relevant to women, youth and transgender individuals. The Prevention Group developed a working definition of the individuals at the highest risk for contracting and/or transmitting HIV and what are considered to be the highestrisk activities for HIV in San Diego County. These definitions focus on behaviors and were adapted from the definitions used in the Centers for Disease Control and Prevention (CDC) Funding Opportunity Announcement PS10-1003 released in August 2009. Highest-risk individuals for contracting and/or transmitting HIV: Persons of unknown status engaged in high-risk activities that have either never tested or have engaged in high-risk activities since their last test, including the window period HIV positive persons out-of-care and engaged in high-risk activities with someone of unknown status Highest-risk activities: if within the past 12 months, an individual has had unprotected sex, used substances while engaged in sexual activity or through injection, or has had an STD
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To prevent HIV, it is essential to conduct risk reduction and harm reduction efforts with these priority populations. Risk reduction efforts help identify behaviors that are less harmful (The Body, n.d.) and risk reduction efforts focus on behavior change to decrease the risk of harmful activities (CDC, n.d.). These types of programs are conducted without judgment and are referred to here as sex positive. Fundamental to all sexual health is sex that is consensual, non-exploitive, mutually pleasurable, shared values between sexual partner(s), protected against sexually transmitted infections, HIV and pregnancy (when desired) and safe from violence and injury (Braun-Harvey, 2010).
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HIV EDUCATION AND PREVENTION GOAL AND OBJECTIVES Developmental Process The California Department of Public Health, Office of AIDS (CDPH/OA) requested that select local health jurisdictions (LHJs), including the County of San Diego, develop a plan to address the HIV prevention and counseling and testing needs of African American gay men/men who have sex with men (MSM) by July 1, 2007. In response to this request, the Prevention Groups Epidemiology and Target Populations (E&TP) Committee collaborated with the HIV, STD and Hepatitis Branch of Public Health Services (HSHB), the Epidemiology Section of the County of San Diego Epidemiology and Immunization Services (EIS), the Kemet Coalition, the Faith-Based Working Group (FBWG), ONTRACK (a non-profit human services consulting firm that provides cost-free technical assistance and training services to enhance HIV/AIDS prevention services for African Americans), community leaders, providers and infected/affected individuals to develop the African American Gay Men/MSM HIV Prevention and Counseling and Testing Action Plan for San Diego County (AAAP). The AAAP was fully developed during the formative phase from March 2007 to December 2007 and includes HIV counseling and testing (HCT) and education and prevention (E&P) components. The AAAP was implemented February 2008. Since that time, progress toward the goals and objectives has been tracked and reported in the biannual Progress Reports for Local HIV Prevention Programs submitted to CDPH/OA in February and August of each year. In March 2008, members of the E&TP Committee determined the need for and initiated the development of the Plan de Accin para Latinos: HIV Prevention and Counseling and Testing Action Plan for Latinos in San Diego County (PAL). During the formative phase from June to December 2008 and following the same methods used to develop the AAAP, the PAL, a non-funded, non-mandated plan, was drafted and progress toward the goals and objectives has been tracked and reported in the bi-annual Progress Reports for Local HIV Prevention Programs submitted to CDPH/OA in February and August of each year. The Comprehensive Plan for HIV Prevention Services for San Diego County, 20072010 included recommendations to prevent HIV in San Diego Countys African American and Latino communities. These recommendations were incorporated, as appropriate, into the goals and objectives of both the AAAP and PAL. Both action plans have been implemented as a collaborative effort between the County of San Diego and various community partners in order to leverage resources and support and effectively execute the activities outlined in the action plans. (Both the AAAP and PAL are available at www.sdhivprevention.org.) Upon further consideration by the Prevention Group, its committees, advisory groups, community partners and HSHB, it was determined that many of the HIV prevention goals and objectives included in the prevention section of the AAAP and PAL were
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applicable to all HIV education and prevention activities with all priority populations and racial/ethnic groups. However, it was believed barriers to accessing education and prevention services may exist that are unique for each population. In the following section, these common HIV prevention goals and objectives are outlined and the unique barriers as well as strategies to address these barriers are presented in more detail. Goals and Objectives for HIV Education and Prevention Activities The County of San Diego adopted the action plan goals presented by CDPH/OA at the statewide meeting January 17, 2007. The goal specific to HIV education and prevention services was adapted for the current HIV education and prevention plan. Additional data and information gathered during the formative phase of each action plan was used to inform the development of the final AAAP and PAL goals and objectives. To create plans aligned with existing state and national efforts and establish linkages to HCT and Care and Treatment (C&T), both action plans contain goals and objectives specific to HCT and C&T in addition to E&P. Minor edits incorporated into the original E&P goals and objectives outlined in the action plans have been incorporated into the following list of goals and objectives applicable to all HIV education and prevention activities for all priority populations and racial/ethnic groups. Goal: Provide effective HIV education and prevention services for priority populations to the extent funding and resources are available through the following process objectives: 1.1. Increase and maintain access to and utilization of education and prevention services for priority populations as funding permits. 1.1.1. Conduct analysis of service delivery data and risk data to establish a baseline to measure outcomes of prevention services for priority populations. 1.1.2. Collaborate with local HIV providers, faith-based community and non-HIV specific organizations to plan and coordinate HIV/AIDS prevention events and activities targeting priority populations. 1.1.3. Diversify outreach and education locations, dates and times based on community suggestions so as to most effectively reach the priority populations, including websites and venue-based sites. 1.1.4. Increase efforts to recruit and train individuals from the priority populations to become HIV prevention health educators, expanding search to non-HIV organizations, faith-based community and local colleges/universities. 1.1.5. Continue efforts to recruit and retain representation from the priority populations and those organizations who directly serve the priority populations on the Prevention Group and other statewide and national boards and commissions. 1.2. Provide on-going training and support for HIV E&P providers as funding permits. 1.2.1. Provide trainings on community resources (both HIV and non-HIV), innovative and effective outreach and risk reduction techniques, program development and evaluation, evidence-based interventions, etc.
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1.2.2. Work with local, state, national organizations and planning groups to assist in meeting the goals and objectives of local action plans and HIV education and prevention plans. 1.3. Identify and implement effective prevention strategies as funding permits. 1.3.1. Collaborate with community partners to conduct an on-going needs assessment of the priority populations. 1.3.2. Explore research opportunities with local academic and research institutions that could assist in identifying and implementing innovative, effective, culturally-appropriate HIV education and prevention interventions. 1.3.3. Explore funding sources and resources to conduct formal program evaluations of local interventions. 1.4. Collaborate and coordinate, as feasible, with HCT and C&T planning services for early identification of people unaware that they are living with HIV/AIDS and providing linkage to care. The evaluation of the education and prevention process objectives listed above will be measured to the extent funding and resources are available according to the following outcome objectives: 1.5. Evaluate service delivery data for County funded HIV education and prevention services including analysis of data by demographics (gender, race, ethnicity and region), priority populations and outcomes of services received. 1.5.1. Evaluate effectiveness of HIV prevention interventions with priority populations by gender, race, ethnicity and region using the Prevention Outcome Database (POD). 1.6. Monitor progress serving priority populations based on gender, race, ethnicity and region. 1.6.1. Review and evaluate HIV prevention providers progress in addressing identified gaps in HIV education and prevention services in quarterly progress reports (QPRs). 1.6.2. Continue tracking of all activities addressing specific objectives of the AAAP and PAL.
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BARRIERS AND STRATEGIES TO ADDRESS BARRIERS FOR HIV EDUCATION AND PREVENTION SERVICES The previous section contains the goals and objectives for this HIV prevention plan derived from action plans to address HIV prevention needs in the African American and Latino communities in San Diego County. The development of these plans was facilitated by meetings with staff from the HIV, STD, and Hepatitis Branch of Public Health Services (HSHB), consultants and advisory groups: the Kemet Coalition and its subcommittee, the Faith-Based Working Group (FBWG) and the Coalition of Latino AIDS Service Providers (CLASP). (A description of the advisory groups may be found on pages 40-44.) Following this model, in March 2010 staff from HSHB met with members of each advisory group to brainstorm prevention strategies for specific populations in San Diego County. Members of each advisory group provided information on barriers to accessing HIV education and prevention (E&P) services and subsequently made recommendations for strategies to address these barriers. As these qualitative data were analyzed, it became apparent that many, but not all barriers to accessing services were true for all populations engaged in high-risk activities. Also worth noting, when community groups were asked to discuss access to education and prevention services for individuals engaged in highest-risk activities in their respective populations, they were often inclined to share information about access to all services (i.e. care and treatment services) by all members of their communities and not just those at highest risk. This was captured in the following table, with a note in the Strategies to Address Barriers column if the service is not an HIV E&P funded activity, which this plan is tasked to address. Table 11 BARRIERS AND STRATEGIES: ALL POPULATIONS ENGAGED IN HIGHEST-RISK ACTIVITIES Barriers to Accessing Services Stigma is a barrier for all high-risk populations and can be based on: culture, social norms, peers, self, family and community, as well as in conjunction with other behaviors such a drug use, and sexual orientation Strategies to Address Barriers Normalizing testing and making it a routine part of health care can help to reduce stigma; testing is not an E&P funded activity but E&P service providers refer to HIV testing
Language in prevention materials is not Design materials for all literacy levels always appropriate for the literacy level and provide oral information as of those in need of the information appropriate HIV is seen as manageable without serious health consequences Continue to provide information on the health consequences of HIV disease
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Table 11 (Continued) BARRIERS AND STRATEGIES: ALL POPULATIONS ENGAGED IN HIGHEST-RISK ACTIVITIES Barriers to Accessing Services Many individuals engaged in highestrisk activities do not know what HIV education and prevention services are and that there are health educators available to offer information about overall and sexual health; in some instances there is the incorrect assumption there is a cost for these services Service delivery requirements following county, state and federal guidelines can limit providers ability to keep up with the most effective prevention strategies Lack of support services such as childcare and transportation Strategies to Address Barriers Clients and providers need to have sexual health discussions and when appropriate, refer to prevention providers; clinics can orient clients to answer questions and address issues related to accessing services; increasing bridge workers can link newly diagnosed HIV positive individuals to care and education and prevention services Encourage providers to communicate the trends in risk behaviors and innovative strategies to reduce risk behaviors to funders directly in reports and applications for funds Support services are not fundable E&P activities; when possible offer prevention services in conjunction with programs that offer these services Address individual issues on a caseby-case basis and maintain a clientcentered approach
There are many issues that affect reaching and retaining individuals for prevention services, such as individuals are afraid to find out their HIV status, clients discontinue with services, individuals do not want to run into people they know, or they report not having time Homelessness and all the factors that lead to and are the result of homelessness as they relate to increasing an individuals risk for transmitting or contracting HIV
Provide referrals to housing services as available (housing is not an E&P funded activity).
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Table 11 (Continued) BARRIERS AND STRATEGIES: ALL POPULATIONS ENGAGED IN HIGHEST-RISK ACTIVITIES Barriers to Accessing Services Recent budget cuts resulting from loss of state general funds for HIV education and prevention services in California resulted in a two-thirds reduction in direct HIV education and prevention services; other budget cuts have resulted in cuts to other social and health services; the overall result is more risk and fewer services to support risk reduction Strategies to Address Barriers Providers continue to leverage resources to offer risk reduction services in conjunction with other services; HSHB distributes funding announcements and support in identifying funding opportunities
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Table 12 BARRIERS AND STRATEGIES: MEN WHO HAVE SEX WITH MEN (MSM) BEHAVIORAL RISK GROUP Barriers to Accessing Services Some MSM see private practice doctors and do not access HIV education and prevention services; it is not always as easy to identify MSM during outreach Prevention fatigue; MSM are tired of hearing prevention messages and/or thinking about it during each sexual encounter MSM in regions outside of the Central region have heard fewer prevention messages; programs need to find ways to access MSM in all regions Keeping up with technology is a barrier for HIV E&P providers (i.e. Grindr, a cell phone enabled application for MSM seeking sexual partners) Gay/MSM servicemen in San Diego have specific HIV prevention needs Strategies to Address Barriers Provide information on HIV education and prevention services to private providers and conduct outreach in venues where MSM congregate Hierarchy of risk should be utilized to help those with prevention fatigue make informed choices As feasible, continue behavior change campaign activities in all regions
Explore if there are any policies for conducting prevention outreach on phone enabled applications; explore I-phone application for finding prevention services Address MSM and risk as it relates to those in the services, specifically HIV negative MSM who are often uneducated and need more information than HIV positive MSM
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Table 13 BARRIERS AND STRATEGIES INJECTION DRUG USERS (IDUs) BEHAVIORAL RISK GROUP Barriers to Accessing Services Strategies to Address Barriers
IDUs are difficult to serve because their Providers need to be consistent in offering services and referrals to IDUs lives are often unstable and be aware when IDUs are ready to make changes Conducting multi-session groups with IDUs has not been effective due to the fact that they do not return for all sessions It takes a long time to develop rapport with many IDUs Provide one-time groups and education in detention and treatment facilities
Providers need more time out in the field to build rapport; it is important to have outreach workers represent the population
Some IDUs do not get treatment for Educate IDUs on how to advocate for abscesses because of the way they are themselves to access and receive treated when service providers learn medical services as needed they are IDUs Transportation is a barrier; an individual may be willing to go to an appointment but is unable to get there IDU youth accessing risk reduction services has increased and there are limited staff that are youth to provide services There are limited hepatitis C treatment options As feasible, meet IDUs where they congregate (transportation is not an E&P funded activity) Collaborate with youth-serving provider(s)
As feasible, continue to provide risk reduction services
Table 14 BARRIERS AND STRATEGIES: PARTNERS OF MSM AND/OR IDUs BEHAVIORAL RISK GROUP Barriers to Accessing Services Partners may not feel comfortable getting services that specifically target MSM and IDUs Strategies to Address Barriers Refer to Partner Services program that is specifically designed to support partners that may be at risk
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Table 15 BARRIERS AND STRATEGIES: AFRICAN AMERICANS ENGAGED IN HIGHEST-RISK ACTIVITIES Barriers to Accessing Services Lack of health care providers that are peers or members of the AfricanAmerican community Prevention materials that depict, imply and specifically target gay men may be appropriate for those who identify as gay but not those who do not identify as gay but engage in risky activities with same sex partners Strategies to Address Barriers Recruit African Americans as health educators Ensure African Americans are involved at every level, from start to finish, in the development of materials by utilizing community gatekeepers and focus groups; ensure African American representation on the Materials Review Panel; develop materials that are neutral and do not depict, imply or specifically target gay men Establish rapport that includes trust and ensure confidentiality of clients Incorporate more oral components to HIV education and prevention services Continue programs targeting African Americans; ensure African Americans are involved at every level, from start to finish, in the development of programs by utilizing community gatekeepers and focus groups
Confidentiality and privacy; for example a community member stated, I dont want others involved in my business Many African-American language and learning styles are unique Need for programs that address the specific needs and concerns of African Americans
For more information on HIV prevention efforts for African Americans in San Diego County , please see the African American Gay Men/MSM HIV Prevention and Counseling and Testing Action Plan for San Diego County available at www.sdhivprevention.org.
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Table 16 BARRIERS AND STRATEGIES: HIV POSITIVE INDIVIDUALS ENGAGED IN HIGHEST-RISK ACTIVITIES Barriers to Accessing Services Many HIV positive individuals are unaware of their status, able to accept diagnosis and/or are unaware of their risk of transmitting HIV disease Strategies to Address Barriers Increase testing of those who are unaware of their status; normalize testing by making it a routine part of health care; E&P providers refer to testing as testing is not an E&P fundable activity Utilize motivational interviewing and stages of change to support individuals in behavior changes they are willing and able to make Continue efforts to develop a more comprehensive and holistic health system; offer social networking and educational activities that are engaging; provide hierarchy of risk to help those with prevention fatigue make informed choices Integrate HIV education and prevention into other existing programs, groups and/or drop in services
Many HIV positive individuals exhibit an inability to plan and control behaviors Many HIV positive individuals experience fatigue and are overwhelmed with messages associated with HIV prevention
Lack of services, specifically in the East, Southeast and North; with reduction in funding, there are no longer any drop-in services available with E&P funds Lack of HIV positive peer providers Lack of knowledge about prevention services for positives as well as knowledge about HIV disease and transmission of the disease
Encourage HIV positive peer providers and positive speakers Offer consistent messages; increase HIV education and prevention thereby normalizing HIV; add Q&A to websites for newly diagnosed; promote, offer and provide Partner Services; get information on resources out to the community
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Table 17 BARRIERS AND STRATEGIES: LATINOS ENGAGED IN HIGHEST-RISK ACTIVITIES Barriers to Accessing Services Some males exhibiting machismo may not support their partners in getting tested Latinos can be reluctant to ask for help; for some Latinos, it is perceived as a sign of weakness for others to know they may need services Status of citizenship and fear about how HIV results will affect becoming documented Strategies to Address Barriers Establish effective outreach strategies to reach Latinas unaware they are at risk and promote testing Partner with parent/teacher groups; offer groups specifically targeting Latinos; use current group participants to recruit others Partner with the Migrant Education program and other organizations that serve individuals who may be undocumented and offer other legal and support referrals Provide services and materials in Spanish with consideration of different dialects and levels of literacy Establish rapport that includes trust and ensure confidentiality of clients; be aware that it takes time to establish rapport; health educators such as promatoras, with established contacts are valuable resources Provide educational information at sites such as laundromats, low-cost day care centers, liquor stores, check cashing stores, churches, treatment programs for drug and alcohol abuse, trolley/bus stations, hiring halls for undocumented workers, Home Depot, food banks, homeless shelters and parks offering sports and other activities Offer services after hours
Many monolingual Spanish-speakers experience language barriers Many Latinos experience issues with trust and confidentiality
Information is lacking in the communities where people live, work and play
Some Latinos cannot take time off during the day because they may risk losing their job
For more information on HIV prevention efforts for Latinos in San Diego County , please see the Plan de Accin para Latinos: HIV Prevention and Counseling and Testing Action Plan for Latinos in San Diego County available at www.sdhivprevention.org.
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Table 18 BARRIERS AND STRATEGIES: TRANSGENDER ENGAGED IN HIGHEST-RISK ACTIVITIES Barriers to Accessing Services Reluctance to access medical services due to the lack of culturally sensitive and competent medical staff; many medical providers are unaware of transgender issues Strategies to Address Barriers When feasible, provide medical professionals with training to acknowledge transgender identities and lives and how to provide competent and appropriate HIV prevention and care services and eliminate discrimination in medical settings Train transgender peer educators to help facilitate HIV education and prevention interventions, thus creating a sense of empowerment and an opportunity to further develop and practice prevention skills When feasible, explore ways to incorporate HIV education and prevention services into other health and social services such as medical care, mental health services, substance abuse treatment and job training and placement programs to promote overall health and wellness for transgender individuals Conduct HIV education and prevention services in an environment where it is safe to express transgender identity; this will serve as an incentive to participate and also combat isolation and alleviate shame caused by social stigmatization Continue encouraging transgender individuals to participate in HIV education and prevention program planning, development and implementation by collaborating with transgender community groups to distribute schedules, event fliers and employment opportunity announcements
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Many transgender individuals mistrust mainstream government organizations, health care providers and other LGBT organizations due to previous negative experiences Obtaining stable housing and employment take priority over reducing HIV risk and must be addressed before HIV prevention efforts can be effective
Psychosocial and socioeconomic factors such as poverty, low selfesteem, depression, feelings of isolation, rejection, shame and powerlessness
Lack of transgender representation among medical staff and HIV E&P providers
Table 19 BARRIERS AND STRATEGIES: WOMEN ENGAGED IN HIGHEST-RISK ACTIVITIES Barriers to Accessing Services Women are not identified as a priority population due to reduction in services and need to prioritize services to those at highest-risk; services are focused on men and IDUs and women receive prevention services as a result of being sex or needle sharing partners; targeting women only as partners can be ineffective Women do not always know that they are at risk; therefore categorizing them as high risk can be complex; female stereotypes portray women as low risk; and social power imbalance puts less control with women Strategies to Address Barriers Access to services for women at highest risk is included in this plan and priorities where revised to include all ages, genders, races and ethnicities; encourage women to be a part of strategic planning on all levels including members of the Prevention Group; as funding permits, target services to the specific needs of women Peer and female advocates can educate women on how to advocate for themselves; empower women to be self-sufficient through support groups for HIV positive women; increase education for women that are at risk explaining the health risks of HIV and importance of getting tested; include the role of social, economic, racial and sexist issues impacting access to services; and consider co-factors not just behaviors Target outreach towards women at highest risk; hire bilingual women as health educators; explore ways to link with other social services and health care providers; explore alternative ways to outreach to women such as local campaign (Know Your Status); develop a pamphlet for women; be innovative and engage industry, commerce and others to promote messages to women; and access women where they live, work and socialize
Lack of outreach and services for women; very little female-centric outreach is conducted; there is no prevention outreach targeted specifically to young or older women; and there is minimal female focused outreach outside of outreach with female IDUs
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Table 19 (Continued) BARRIERS AND STRATEGIES: WOMEN ENGAGED IN HIGHEST-RISK ACTIVITIES Barriers to Accessing Services Services are designed to target men and do not engage women; and interventions are not designed to teach women to protect themselves Women are not receiving adequate education to reduce their risk in primary care, schools or media; materials developed for programs primarily serving men lack cultural relevance to women Strategies to Address Barriers As feasible, develop programs to reach women with culturally responsive interventions; encourage communitybased organizations (CBOs) to seek funding; and encourage collaboration
Promote HIV risk reduction education in schools (this activity is under the purview of the education system and is not an E&P funded activity) and health care settings; use social media (i.e. Twitter); as funding permits, develop a pamphlet for women; distribute current education and prevention service pamphlet which is targeted to all populations Stigma (particularly since women are Support HIV positive women in not perceived as being affected by HIV) becoming role models Lack of child care, transportation and Offer services in conjunction with services that offer child care, employment transportation and employment development (these service are not E&P funded activities)
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Table 20 BARRIERS AND STRATEGIES: YOUTH ENGAGED IN HIGHEST-RISK ACTIVITIES Barriers to Accessing Services It is difficult to reach gay/MSM youth and youth at highest risk Many youth lack knowledge, do not perceive themselves to be at-risk, do not know where to get tested and lack general HIV education Strategies to Address Barriers Target outreach where youth at highest risk congregate and where they access services Refer to free testing; encourage HIV testing as a routine part of their preteen physical and vaccinations; encourage testing of youth receiving substance abuse, mental health and other services; E&P providers refer to testing, but it is not an E&P funded activity Offer support groups targeting youth at highest risk to educate and empower other youth; when talking with youth about HIV, be candid and honest while also using humor and non-textbook language; be real and on their level As feasible, develop behavior change campaigns and materials geared towards youth and not just MSM; explore utilizing materials from Centers for Disease Control and Prevention (CDC) funded youth programs As feasible, partner with education system to keep apprised of available HIV prevention education; although addressing education is not a funded E&P activity, there is a need to improve legislation to designate specific HIV course curriculum and provide resources to educate youth at highest risk; provide HIV education to youth that may be vulnerable to engaging in highest-risk activities Collaborate with CBOs that offer social and health services to youth
Many youth lack trust and are fearful of knowing their status, blood draw, lack of confidentiality and parents finding out
Lack of behavior change campaigns specifically targeting highest-risk youth
Education about HIV in schools is not consistent and accurate, and E&P funding is not available for this activity; some schools do not allow HIV presentations for youth or severely limit what can be discussed
Youth receiving social and health services are often not educated about risk and risk reduction strategies
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FUTURE DIRECTIONS FOR HIV EDUCATION AND PREVENTIONSERVICES Bio-Medical Approaches to HIV Prevention The HIV prevention community is working to integrate and become more proficient at offering approaches to HIV prevention that encompass bio-medical interventions in addition to behavior change promotion and harm and risk reduction. For groups at high risk for HIV a test early and often approach is recommended both for sexually transmitted diseases (STDs) and HIV. Sexually Transmitted Diseases (STDs) STDs increase the risk of HIV transmission and acquisition by at least two to five times, underscoring the importance of screening and testing for STDs and prompt treatment of patients with STDs and their sex partners. Helping reduce STD prevalence in the community will aid HIV prevention efforts. Primary care and prevention providers must use all avenues to assess patients for risk of infection, including taking a sexual history and then screening appropriately for STDs and, if necessary, providing referrals for treatment. HIV Encourage regular testing for high-risk groups, as knowing a persons status early can help them avoid transmitting to partners and improve their own health by accessing HIV primary health care early. Also, regular testing approximately two times a year for highrisk groups helps increase serostatus knowledge. Keeping to a regular schedule and not just at times after perceived exposure helps to alleviate some anxiety around routine testing. Further, for those individuals who have high-risk perceived exposures, the Early Test, which can detect HIV infection 7-10 days after exposure, may help the identification of people in the window period. Letting people know they are in the acute or early stages of HIV infection, which is the most infectious time, will further help reduce infections. The use of antiretroviral therapy also has potential for preventing new HIV infections both for people who are HIV negative (PEP and PrEP) and HIV positive (standard treatment). Anti-Retroviral Therapy (ART) Use of ART by individuals living with HIV/AIDS has improved long-term survival rates and the physical well being of many. By reducing detectable HIV viral loads through the use of ART, infectiousness is reduced, supporting efforts to prevent transmission of HIV to others. There is the possibility that treatment optimism may cause an increase in sexual risk behaviors in some communities (CAPS, 2003). Expanded use of ART may reduce HIV incidence and eventually HIV prevalence at the population level, assuming significant behavioral HIV risk disinhibition does not occur (CAPS, n.d.). In a city with a mature HIV epidemic where the majority of individuals have known HIV status, the successful application of widespread ART would prevent large numbers of HIV incident
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cases and produce a decline in HIV prevalence when combined with annual HIV testing to detect new cases (CAPS, n.d.). Post Exposure Prophylaxis (PEP) PEP is the use of ART for people who are HIV negative but report a high-risk HIV exposure. PEP is a high dose ART regimen that stops the progression of HIV after potential exposure to infected blood or a needle puncture. PEP prevents HIV from taking hold in someone who has been exposed to HIV through occupational or sexual exposure. It is typically utilized in occupational settings but can be extended to nonoccupational exposures, i.e. non-PEP. The guidelines for PEP use should be based on current Centers for Disease Control and Prevention (CDC) guidelines. For PEP to be effective, it must be administered almost immediately after exposure. The best results of PEP depends on instituting ART as soon as possible, at less than 24 hours but up to 72 hours, after exposure. Also, PEP effectiveness depends on the accurate serostatus diagnosis of the person requesting PEP; therefore, rapid HIV testing at the time of the provision of PEP and methods to determine that person is not in the acute window period stage, i.e. Early Test, would be optimal. PEP also has potential side effects and is cost prohibitive. The perception of PEP as a day after pill that is widely available could potentially undermine safer sex messages and prevention efforts. Pre Exposure Prophylaxis (PrEP) Similar to PEP, described above, PrEP is the use of ART by individuals who have a high likelihood of being exposed; ART is theoretically used to decrease the risk of acquiring HIV infection. Research trials are currently ongoing but results are pending. If it is found useful, procedures should be evaluated locally. On the Horizon. In addition to trials into PrEP as discussed above, other biomedical interventions like vaccines, which have had recent encouraging results from the Thai trial, microbicides, which have multiple studies ongoing, and treatment of depression and psychological comorbidities should all be evaluated. HIV Counseling and Testing In the United States, the demographics have changed significantly over the course of the HIV/AIDS epidemic decreasing effectiveness of risk-based testing in some communities. In response to this and other factors, the CDC has modified its recommendations for HIV testing. The CDC recommends incorporation of routine voluntary HIV screening with an opt-out screening process into routine health screening and pre-natal screening panels in all health care settings. Prevention strategies that include a universal HIV screening component may be effective. The rates of HIV screening are higher where opt-out screening is provided than at opt-in programs (CDC, 2006). Additionally, rapid testing is recommended, where feasible, to increase the number of testers who receive their results. In California, although mass testing campaigns have been implemented in the past, targeted testing efforts are being encouraged by the California Department of Public
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Health, Office of AIDS (CDPH/OA). This is in part due to the higher rates of HIV infection in ethnic communities and the disproportionate representation of females of color among AIDS cases. In light of limited financial resources and a growing population of people living with HIV/AIDS, it is anticipated that targeting testing and prevention efforts toward communities most likely to be at risk may help to stem the overall epidemic. CDPH/OA requires a focus on testing for high-risk individuals that are reflected in the priority populations. For goals and objectives to address HIV counseling and testing (HCT), please refer to the action plans developed to address HIV education and prevention (E&P) and HCT in communities that are disproportionately infected/affected by HIV (County of San Diego 2008) and (County of San Diego 2010). A description of the development of the action plans can be found on page 57. The goal related to testing is as follows: Goal: Increase HIV Counseling and Testing services for high-risk communities that are disproportionately affected by HIV (such as Latinos and African Americans). HIV Names Reporting April 2006 California law (SB 699) was changed to require the reporting of HIV infection by name instead of code. This was done to ensure that the State of California remains competitive and eligible for federal Ryan White funding which is directed to areas most heavily impacted by HIV/AIDS and funds HIV primary care and treatment services for people living with HIV/AIDS. All AIDS cases have been reported by name. (NOTE: CDC does not receive any identifying information on reported HIV and AIDS cases.) In 2009, the State of California, under the direction of the CDC, adopted the enhanced HIV/AIDS Reporting System (eHARS) to better facilitate case information. There have been a number of issues and barriers associated with this new system that have prevented local health jurisdictions (LHJs), including San Diego County, from having data for analyses and planning purposes. The Epidemiology Section of Epidemiology and Immunization Services (EIS) has developed a database to analyze local data. Because of these delays, a number of reports and requests have not yet been processed and produced, but the Epidemiology Section is working closely with CDPH/OA to address these issues in the near future. System Integration People with HIV/AIDS are living longer, which puts a greater importance on the integration of HIV education and prevention, counseling and testing services, care and treatment and support services outside the HIV/AIDS system of care. All entities play a role in providing referrals, avoiding duplication of services and providing services that complement those provided by other agencies and organizations. Conferences and cross-training involving providers from different systems of care can improve the ability of providers to offer appropriate referrals. Finding Common Ground conferences held in San Diego County have brought the HIV, alcohol and drug and mental health systems of care together. At these conferences, providers learn more about their clients multiple needs and how best to address those needs. Further system integration is
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fostered through offering HIV prevention trainings to both HIV E&P providers and other service providers. The HIV prevention community is working to integrate and become proficient at offering approaches to HIV education and prevention that encompass behavior change promotion and harm and risk reduction at all of the services delivery sites that touch people at high risk for contracting or transmitting HIV. One of the most important partners in support of HIV education and prevention efforts are the Ryan White funded HIV care and treatment service providers. The Ryan White HIV/AIDS Treatment Extension Act of 2009 (RWTEA) was signed into law October 2009 to extend four years through 2013. The legislation included a new directive that onethird of the competitive score for Part A funding be based on grantees ability to identify new HIV positive individuals and link them to care. The directive requires HIV planning councils and grantees to determine the size and demographics of the estimated population unaware of HIV status; provide quantifiable data on the number of individuals tested for HIV, made aware of their status, including number testing positive, and referred to appropriate treatment and care; and development of a strategic plan including a description of the state and local initiatives as the basis of the plan. Focal points of San Diego Countys plan now underway are HIV counseling and testing and partner services (PS), linkages to geographically dispersed early intervention service and early intervention programs and training and education of public and private providers. The local draft plan includes: an annual estimate of those unaware they are living with HIV, gathering data on testing, disclosure, partner services and referrals to medical care, exploring opportunities to acquire additional data (CDC, private testers, hospitals) and getting data entered into LEO. Below is a summary of the nine components of the action plan: (1) Improve and streamline internal planning and coordination between the HIV, STD and Hepatitis Branch of Public Health Services (HSHB), HIV care, E&P, HCT and PS. (2) Expand the gap analysis used for planning E&P services to compare HIV/AIDS surveillance and HCT data with E&P and Ryan White Part A services to better strategically target services to unaware or at-risk groups. (3) Expand HCT services with RW Part A funds, in coordination with geographically dispersed EIS, to identify individuals unaware of their status and link them with medical services immediately upon diagnosis. (4) Improve, expand and promote PS assistance with self-notification or dual/assisted notification of partners or voluntary anonymous third party notification for referral of needle sharing and sex partners to HCT. County HSHB HCT/Field Service Communicable Disease Investigators (CDIs) will increase marketing of PS through conducting presentations to all community partners. The intent is for community provider staff to become more familiar with the County CDIs, have a personal connection and contact for PS and to re-enforce provider understanding that County CDIs have the capacity to confidentially contact at-risk partners in the field and through the internet. The goal is to have the PS message consistently and continually offered by everyone encountered by the individual in the continuum of
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education and prevention, testing and care services or any program (i.e., mental health, substance abuse, sexually transmitted disease, etc.) that touches the HIV positive individual so that an opportunity is not missed if and when that individual becomes willing to discuss partners. (see Appendix H for Partner Services Summary) (5) Create linkages or dual access for CDIs between LEO and the AIDS Regional Information and Evaluation System (ARIES) to facilitate ability to follow individuals from testing into RW medical care and other services and to facilitate extended follow-up if further assistance is required to access or maintain care. (6) Expand, as feasible, the confidential Early Test (Nucleic Acid Amplification Test), which detects HIV up to one week after exposure, into the County HCT clinic; offer to individuals who test negative for HIV antibodies but may still be in the acute infection window period before antibodies develop. (7) Utilize local Physicians Bulletin and Monthly STD Report to promote HCT and PS among private providers (bulletins and reports available at www.stdsandiego.org). (8) Integrate HCT and STD services with opt-out HIV testing in the County STD clinic. (9) Convene a workshop for HIV, mental health and substance abuse treatment providers with a focus on coordinating efforts through HCT, PS and EIS to identify unaware people living with HIV/AIDS and link them to care. Building upon collaborative efforts and strategies, plans for identifying those with HIV/AIDS who are unaware of their status, informing them and referring them into care will be fully developed and coordinated through the Continuum of Care (CofC) committee, co-sponsored by HIV Health Services Planning Council (Planning Council) and HIV Prevention Community Planning Group (Prevention Group). Progress to date includes the following. In December 2009, the Grantee (HSHB) informed the Planning Council of the new requirements to identify HIV positive individuals unaware of their status, test them and link them to care and verified with the federal Health Resources and Services Administration (HRSA) that HCT can be funded with RW Part A funds to address any identified gaps in meeting this new directive. In January 2010, the Grantee drafted the plan outlined above and submitted it as part of a Supplemental Ryan White Part A application (available). The Grantee informed the Planning Council of funding requirements for HCT, and the Planning Council approved it as a funding priority. In February 2010, the plan was reviewed at the Prevention Groups Prevention Strategies and Evaluation Committee (PS&E), which came to consensus to incorporate the plan as part of this Future Directions section of the Plan for HIV Education and Prevention for San Diego County, 2010-2013 (this document). A specific objective to collaborate and coordinate as feasible with HCT and HIV Care & Treatment planning and services for early identification of people living with HIV/AIDS and linkages to care was added to this plan (see objective 1.4, page 59). Beginning in March 2010, County Public Health Services staff representing HIV/AIDS Epidemiology, HIV Education and Prevention, HIV Counseling and Testing, Partner Services, Ryan White Care and Treatment, STD Surveillance and Prevention, and Planning Council and Prevention Group support staff began meeting on a monthly basis to improve integration of planning and services by strategizing how best to collect,
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analyze and report required data, download and incorporate data on local testing from the CDC and survey private laboratories conducting HIV and STD tests for local residents. Beginning in mid-May 2010, one-time Ryan White Minority AIDS Initiative (MAI) funds targeted to people of color will be used to provide additional HCT, expand Targeted Client Advocacy with a focus on Partner Services (PS) linked to HCT, offer care and prevention provider trainings on PS, create a targeted outreach campaign to address PS, evaluate MAI PS projects and enhance/improve tracking mechanisms for testing, disclosure and linkage to care. A HRSA Peer Center webcast in early May 2010 was used as an opportunity to engage HIV positive peer advocates in discussing how best to implement and support PS. In summary, County of San Diego and community partners are committed to an overall strategy of coordinated and integrated planning and services across the continuum of HIV care and prevention to identify and link unaware individuals with medical services immediately upon diagnosis and use support services to keep them in care over time. Community Readiness to Address Substance Use as Risk Factor for HIV As noted earlier in the HIV Prevention Community Planning Process section of this document, a community readiness assessment to address substance use as a risk factor for HIV in the LGBT community was conducted in 2009. The San Diego LGBT community was assessed to be in the initiation stage of readiness, which means that activity or action has been started and is ongoing but is still viewed as a new, incomplete or not entirely effective effort. The goal at this level of readiness is to provide further community-specific information and capacity building such as: Conducting in-service trainings on readiness for professionals and paraprofessionals Planning publicity and media advocacy efforts Conducting consumer interviews to identify service gaps, improve existing services and identify key places to post and distribute information Searching for additional resources and potential funding Beginning or continuing basic evaluation efforts The assessment data were analyzed and presented to prevention providers and community planning group members for feedback in March 2010. The following summary includes prevention strategies that are already considered to be working and should continue and improve upon and next steps for assessing readiness and further developing effective strategies for interventions that the community is ready to implement. Prevention strategies that community members and leaders identified as working and should continue, as funding permits, include: Social marketing (meth and alcohol campaigns) Increased HIV testing (mobile and rapid) Community events (Pride, AIDS Walk) Social events without alcohol
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Successful collaboration among service providers Free condoms Risk-reduction approaches Internet outreach efforts
Recommendations for prevention strategies that community members and leaders identified to continue and improve, as funding permits, include: Employ prevention efforts via internet Implement venue-based strategies including: condoms and lube, free testing, posting information, campaigns, alcohol free events and alcohol/drug policies Avoid monitoring safer sex guidelines at venues; while perceived as effective by some community leaders, it is not supported by community and could be counter productive Community building to strengthen community connection, unite community and foster consensus on priorities as well as offer social support Next steps for assessing community readiness and developing prevention strategies: Make final report available (report available at www.sdhivprevention.org) Acknowledge that plans to take action may be limited by reductions in funding and at the same time may offer new opportunities to address gaps Focus on community empowerment and not blame Clarify actionable findings and how to best develop messages and distribute information Explore further research and funding opportunities The strategies listed above and other future directions presented in this section emphasize the need to continue to learn from ongoing and new research and apply research findings in the planning and implementation of HIV education and prevention efforts.
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REFERENCES
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REFERENCES Braun-Harvey, D. (n.d.). Retrieved on May 3, 2010 from: http://www.bridgingsexualhealth.com California Department of Public Health, Office of AIDS. Education and Prevention 20072010 Program Guidance California Department of Public Health, Office of AIDS. Lessons Learned on the Ground: Four Case Studies in Californias HIV Prevention High-Risk Behavior Change (Social Marketing) Campaign 2004-2007 Center for AIDS Prevention Studies (CAPS) and the AIDS Research Institute (2003). What are injection drug users (IDUs) HIV prevention needs? San Francisco, CA Center for AIDS Prevention Studies (CAPS) and the AIDS Research Institute (n.d.). Retrieved on May 3, 2010 from: http://www.caps.ucsf.edu/pubs/presentations/pdf/charlebois_croi10_2.pdf. County of San Diego, HIV, STD and Hepatitis Branch of Public Health Services (2008). African American Gay Men/MSM HIV Prevention and Counseling and Testing Action Plan for San Diego County County of San Diego, HIV, STD and Hepatitis Branch of Public Health Services (2009). Ryan White Part A Application Fiscal Year 2010 County of San Diego, HIV, STD and Hepatitis Branch of Public Health Services (2010). Plan de Accin para Latinos: HIV Prevention and Counseling and Testing Action Plan for Latinos in San Diego County County of San Diego, Health and Human Services Agency (2009). San Diego County Senior Health Report Doroski, L., Burke, C., Murphy, A. (2009, July). Methamphetamine and HIV in San Diego County: A provider and community comprehensive needs assessment. San Diego Association of Governments. Fishbein, M., Middlestadt, S. E., & Hitchcock, P. J. (1994). Using information to change sexually transmitted disease-related behaviors: An analysis based on the theory of reasoned action. In R. J. DiClemente & J. L. Peterson (Eds.), Preventing AIDS: Theories and methods of behavioral interventions. San Diego Association of Governments [SANDAG] (2009, July). San Diego County HIV Risk Behavior and HIV Prevention Services San Diego Association of Governments [SANDAG] (2010). Fast Facts, San Diego Region [Data file]. Retrieved from: http://www.sandag.org/resources/demographics_and_other_data /demographics/fastfacts/regi.htm Social Science Research Laboratory, San Diego State University (2009). San Diego County LGBT Community Substance Abuse and HIV Community Readiness Assessment
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The Body, the Complete HIV/AIDS Resource (n.d.). Harm reduction and HIV. Retrieved on March 20, 2007 from: http://www.thebody.com/nmai/harm_reduction.html U.S. Centers for Disease Control and Prevention. 20032008 HIV Prevention Community Planning Guide U.S. Centers for Disease Control and Prevention (2009). Funding Opportunity Announcement PS10-1003 Human Immunodeficiency Virus (HIV) Prevention Projects For Community-Based Organizations U.S. Centers for Disease Control and Prevention (2006). Morbidity and mortality weekly report revised recommendations for testing- adults, adolescents and pregnant women in health care settings U.S. Centers for Disease Control and Prevention, National Center for HIV, STD and TB Prevention, Divisions of HIV Prevention (n.d.). HIV health education and risk reduction guidelines. Retrieved March 20, 2007 from: http://www.cdc.gov/hiv/herrg/HIV_HERRG.htm Weisberg, L. & Sanchez, L. (May 15, 2002). Countys Immigration Surge Outstrips Region, Union-Tribune. Retrieved from: http://sports.uniontrib.com/news/reports/census/20020515-9999_1n15immig.html
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APPENDICES
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APPENDIX A GUIDING PRINCIPLES FOR EFFECTIVE HIV PREVENTION INTERVENTIONS
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APPENDIX A GUIDING PRINCIPLES FOR EFFECTIVE HIV PREVENTION INTERVENTIONS Research and practice in the field has shown that effective HIV prevention interventions have certain characteristics in common. The following list is a compilation of ideas from a variety of sources and adapted by the Prevention Strategies and Evaluation Committee (PS&E) in March 2007 and updated March 2010. 1. Interventions are designed according to the results of a comprehensive needs
assessment, including identification of target risk group members level of motivation to change risk behaviors. 2. Interventions are based on behavior change and educational theories, which have been validated by research, empirically driven and systematically evaluated. 3. Interventions are affordable and easy to access by the target population served and are able to respond to other expressed needs of the community. 4. Interventions are culturally responsive, relevant to the targeted population (i.e., consistent with norms, beliefs and attitudes) and include members of the target population in program planning and implementation. 5. Interventions have clearly defined target population, program components and objectives. 6. Interventions focus on behavioral skills, which include how to carry out low risk and safer behaviors as well as how to avoid and cope with high-risk situations (consequence and reality based). 7. Interventions provide messages that are self-affirming and nonjudgmental by staff that is knowledgeable. 8. Interventions have ample duration and intensity to achieve lasting behavior change and provide support and skills necessary to cope with lapses and setbacks in maintaining safer behaviors. 9. Interventions address the social and community norms of the target population so that program participants receive consistent messages and reinforcement for the prescribed behavior change. 10. Interventions are offered to the target group as part of a continuum of health care (e.g., drug and alcohol, mental health and co-occurring disorder treatment, STD screening and treatment, family planning and other health services). 11. Interventions are coordinated with other HIV prevention efforts to maximize area coverage and provision of services. 12. Interventions are aware of and adjust to phenomena that indicate a potential increase for HIV transmission, such as higher pregnancy rates and STD infection. 13. Interventions address and provide referrals to other basic needs of the target population (e.g., housing, food, employment, child care) in order for HIV prevention to be considered a priority. 14. Interventions implement a pragmatic evaluation component, including both process and outcome measurements. 15. Interventions are regularly monitored to ensure implementation is according to plan, projected outcomes are being met and adjustments to interventions are made when appropriate. 16. Interventions work to effect change in community norms to support behavior change.
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APPENDIX B HIV EDUCATION AND PREVENTION INTERVENTIONS AND STRATEGIES
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APPENDIX B HIV EDUCATION AND PREVENTION INTERVENTIONS AND STRATEGIES The following section describes HIV education and prevention interventions approved by the California Department of Public Health, Office of AIDS (CDPH/OA) and proven effective strategies to deliver these interventions. Interventions include: Targeted Prevention Activity/Outreach (TPA) Group Level Interventions (GLIs) Individual Level Interventions (ILIs) Comprehensive Risk Counseling and Services (CRCS) Partner Services (PS) Health Communication Public Information (HCPI) HIV Counseling and Testing (HCT) Strategies include: Harm and Risk Reduction Strategies Abstinence-Based Strategies Venue-Based Strategies Motivational Interviewing
HIV Education and Prevention Interventions The following descriptions of education and prevention interventions comes directly from the Education and Prevention 2007-2010 Program Guidance. At the time of this writing, CDPH/OA reported it is reviewing this program guidance to address significant reductions in funding. Targeted Prevention Activity/Outreach (TPA) TPA is generally conducted by peer or paraprofessional educators, face-to-face with high-risk individuals in neighborhoods or other areas where they typically congregate. A major purpose of TPA is to encourage those at high risk to learn their HIV status. CDPH/OA offered guidance to focus TPA primarily on locating at-risk individuals in highrisk behavioral risk groups (BRGs) and assisting them into HIV counseling and testing (HCT) services. Additional referrals to health education risk reduction interventions and other services that address cofactors and barriers to successful behavioral change can also be made. TPA may also include distribution of condoms and educational materials. Group Level Interventions (GLIs) GLIs are health education and risk-reduction counseling provided for groups of varying size. GLIs use peer and non-peer models involving a range of skills building, information, education and support. Effective GLIs have single or multiple sessions and a written curriculum. These characteristics help participants with long-term behavior
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change. In addition, facilitated support groups that have a focus on risk reduction and skills building can also be effective. Group Counseling Groups may be closed, structured, drop-in and/or support groups related to HIV/AIDS prevention and education. Skill-building Workshop Skill-building workshops teach specific risk-reduction strategies that allow the participant to learn and role-play the skills during the session.
Individual Level Interventions (ILIs) ILIs are health education and risk-reduction counseling provided for one individual at a time. ILIs help participants appraise their behavior, make plans for behavior change and monitor their behavior changes. ILIs also facilitate linkages to services in both clinic and community settings to support behaviors and practices that prevent HIV acquisition and/or transmission. Comprehensive Risk Counseling and Services (CRCS) CRCS (formerly Prevention Case Management) is a client-centered HIV prevention activity with the fundamental goal of promoting the adoption of HIV risk-reduction behaviors by clients with multiple, complex problems and risk-reduction needs. CRCS is a hybrid of HIV risk-reduction counseling and traditional case management, which provides intensive, ongoing and individualized prevention counseling, support and links to other vital services. Partner Services (PS) PS offers people living with HIV support in partner disclosure and notification. Services include disclosure skills building to assist individuals with self-disclosure and dualdisclosure or anonymous third-party notification. Dual-disclosure is defined as counselor assisted self-disclosure to a clients partner. Anonymous third party notification can only be conducted by designated health department staff. The partner is notified that he/she was exposed to HIV and should get tested; however, no identifying information is provided to partner(s) as to who may have exposed this person to HIV. Health Communication Public Information (HCPI) HCPI is the delivery of planned HIV/AIDS prevention messages to targeted populations through one or more means. HCPI messages are designed to build general support for safe behavior, support personal risk-reduction efforts and inform people at risk for infection about prevention services and other services that support the participants behavior change goals. The following describes examples of how HCPI interventions may be implemented.
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Social Marketing/Behavior Change Campaigns Social marketing principles and techniques can be applied to the delivery of HIV prevention messages and activities to target populations at risk of HIV infection through program promotion, risk-reduction interventions, community resources and the development of materials designed specifically for the target audience. Social marketing considers the consumer the center of a process involving four variables: product (commodity, idea or health practice); price (cost to the consumer, such as money, time or effort associated with changing behavior); place (channels of communication and distribution points for products); and promotion (ideas and images used to sell the product). Social marketing can help shape cultural norms through advocacy and modeling of positive behaviors and is a useful tool in HIV prevention. Health Promotion Events Health promotion events utilize booths and other displays where printed information and program materials are distributed during an established event that is patronized by the target audience. It may include participation in a health campaign sponsored by larger health organizations or government agencies, community health fairs and community activities not necessarily health focused such as street fairs, exhibits, festivals, etc. Although such events might offer limited opportunities for specific interventions, a presence at public events raises awareness concerning a specific organization and its services. Community Mobilization Community mobilization is a strategy that involves grassroots outreach and education within a specified neighborhood or community to increase awareness of HIV/AIDS issues and generate greater participation of residents in HIV prevention. This strategy is particularly suited for low-income communities where primary resources are human resources. It is also useful in communities of color where the communities are known and defined and in communities where complacency regarding HIV infection may have manifested such as segments of the gay community. Collaboration with Faith-Based Community There is growing awareness of the role that the faith-based community has in HIV prevention activities, particularly in communities of color. Collaborating with the faithbased community can provide the prevention workers with legitimacy in the given community. This can be crucial when working with disenfranchised communities. Examples of faith-based work can include coordinating health and wellness fairs with churches, encouraging the church leaders to promote education about HIV and testing and working with the various groups that are affiliated with the church. HIV Presentations Presentations conducted in the community that provide basic HIV educational information are also referred to as HIV 101 are HCPI activities. The CDPH/OA has established that educational presentations of this type are not considered groups as
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they do not include a specific skills-building component. These presentations are often appropriate and effective in settings such as detention facilities where detainees are provided with referral information that can support them upon release to accessing services including health education and risk reduction In San Diego County, a variety of HCPI activities have been effective. Upon notification that CDPH/OA was considering eliminating this intervention, HSHB advocated for the continuation of this intervention as well as offering to provide information and training on effective best practices for community level interventions that produce valid outcomes. Although CDPH/OA does not require the measurement or reporting of outcome data (the LEO system is limited in this regard) the locally developed Prevention Outcome Database (POD) tracks and measures outcomes of HCPI activities in San Diego County. Thus, HSHB has data to support the importance and effectiveness of HCPI interventions. The following list of benefits of this intervention was submitted to CDPH/OA April 2010: Benefits of HCPI: behavior change campaigns The document Lessons Learned on the Ground: Four Case Studies in Californias HIV Prevention High-Risk Behavior Change (Social Marketing) Campaign 2004-2007 published by CDPH/OA in November 2008 clearly shows beneficial outcomes of behavior change campaigns conducted over time; campaigns following the CDCynergy model included an evaluation. Outcomes in high-risk target populations indicated two-thirds discussed and/or one-half made plans to discuss status with sexual partners and friends Campaigns have been used to successfully address gaps in services in areas where it is the most difficult to reach high-risk populations including the North and South regions of San Diego County; gap analysis data showed effective campaigns decrease gaps in otherwise under represented groups for prevention services The CDCynergy model permits community driven and innovative interventions that address social norms and build community; formative and evaluation data have been utilized to support service and community planning Strategic Planning Teams have allowed the community to participate in community planning on a smaller scale, preparing them for participation in larger planning bodies Outreach workers have been featured in marketing materials thus strengthening their presence in the community and providing an opening to engage the population during outreach An effective way to get important information out to a large number of people in a short amount of time, examples include: San Diego State University syphilis outbreak, current H1N1 vaccination campaign and national campaigns Data gathered through the formative process allows providers to get an idea of current trends; although used for campaign development, information has been used for other prevention activities
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As technology evolves, how target populations access sexual partners also evolves; through the HCPI formative process, trends are reviewed and utilized to educate prevention providers on new outreach strategies (i.e. online outreach, Facebook, YouTube, Grindr) HCPI activities allow building and strengthening of relationships with LGBT media offering free publicity and providing the opportunity for media to be advocates for HIV prevention; information gathered through the formative process provides material for articles and stimulates community awareness and mobilization Many minority communities only feel that they are being represented in prevention activities if they are seen in marketing materials Consistently having marketing materials in venues frequented by the target population is very "client centered; hundreds of outreach cards are taken from venue-based displays at bathhouses every month; this happens when outreach workers are not present to give them the information but when individuals need the information most Having a marketing presence/branding of prevention activities shows the general population that the "work" is happening; many high-risk individuals might never receive an outreach packet but will see an ad and get information
Benefits of HCPI: health fairs and presentations Program presence at Gay Pride, AIDS Walk, World AIDS Day events and other health and social events is an important venue-based strategy to address risk where it is taking place HIV 101 presentations in detention facilities can identify high-risk individuals for ILI in the detention facility and offer valuable life saving and risk reducing referrals to high-risk individuals while they are detained and upon release San Diego conducted an LGBT Community Readiness Assessment to address substance use as a risk factor for HIV; report showed continued support of venue-based strategies (report available) Members of the target population leave their homes/computers for events Engaging presentations not only provide a venue for people to get together and receive information in a short amount of time, but it also builds community It is more cost and time effective to educate high-risk populations in group settings with an audience rather than prevention provider staff looking for them one at a time on the street Group dynamics allow for joint education and learning from one another's experiences; this can not happen in one-on-one activities HCPIs serve as an avenue to reach a large audience and funnel them into specific services There are several high-risk venues that will only allow providers to implement HCPIs such as bathhouses, detention facilities, etc.
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If this intervention type is eliminated what might be expected: Reduced exposure and access to high-risk populations, leading to decrease in prevention messages and increase in risk behaviors Reduced capacity to prevent HIV; with less funding, fewer staff are now available suggesting that if there is one person in a large geographic region such as the North regions of San Diego County, the best way to make a significant difference to prevent HIV is to utilize strategic community level interventions
HIV Counseling and Testing Confidential and anonymous testing provides a unique opportunity for one-on-one prevention education. HIV test counselors work to educate clients about the disease while initiating personal risk-assessment and behavior-modification discussions in a client-centered manner. For many high-risk clients, it is their first exposure to HIV prevention. Due to the portability of some of the testing modalities, counseling and testing can occur in fixed sites, as part of a mobile van or clinic and during outreach sessions. HIV counseling and testing is not a funded education and prevention activity although HIV education and prevention services include referrals to counseling and testing services.
STRATEGIES Harm and Risk-Reduction Strategies Harm and risk-reduction strategies include policies, programs, services and actions that work to reduce the health, social and economic harms to individuals and communities that are associated with the use of substances and high-risk sexual behaviors. Harm and risk-reduction techniques have been applied successfully to persons using alcohol and/or drugs and/or having risky sex. Harm and risk-reduction focus on the individual who is using or having sex and the potential harm associated with that activity. Interventions associated with harm and risk reduction include promoting the use of clean injection equipment, information on how to reduce the frequency of abscesses, the use of condoms and how to moderate or reduce substance use. Abstinence Strategies Two major approaches can be utilized when incorporating abstinence messages into HIV prevention activities; these are abstinence-only and abstinence-based. Abstinenceonly education promotes the idea that remaining abstinent is the only 100 percent effective way to prevent HIV/STD infection and transmission. Abstinence-only approaches do not provide information about the correct use and effectiveness of condoms and other contraceptive devices. Abstinence-based programs discuss the importance of abstinence as a prevention strategy, as well as comprehensive sex education including the usefulness of condoms if one chooses to have sex. Topics covered in abstinence-based curricula can include information on HIV and STDs,
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personal risk, benefits of protective behaviors and refusal skills. Abstinence-based programs are most effective with youth. Venue-Based Strategies HIV prevention venue-based strategies involve targeting individuals accessing services such as HIV care clinics and other locations, scenes or settings used for sexual and/or drug encounters or for social purposes. Typical venues for interventions are bathhouses, internet sites and circuit parties, which are often gateways to finding partners and can be associated with HIV and STD transmission. Because venues play an important role in the community, they can provide a backbone for fostering norms. Venues are more amenable to change than streets or neighborhoods. Venue-based strategies for HIV prevention include offering venue patrons HIV/STD testing information, outreach, safer sex kits and condoms. Motivational Interviewing Motivational interviewing is a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence. Compared with nondirective counseling, it is more focused and goal-directed. The examination and resolution of ambivalence is its central purpose and the counselor is intentionally directive in pursuing this goal. This strategy is often developed in conjunction with the stage of change theoretical model (see Appendix C).
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APPENDIX C HEALTH BEHAVIOR THEORIES AND MODELS
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APPENDIX C HEALTH BEHAVIOR THEORIES AND MODELS A theory describes what factors or relationships influence behavior and/or environment and provide direction on how to impact them. Theories can help prevention providers frame interventions and design evaluations. When designing or choosing an intervention, theory can show what factors should be targeted and where to focus efforts. Theories can help define the expected outcome of an intervention for evaluation purposes. Also, basing programs on a tested theory gives it scientific support, especially if the program has not been evaluated. Many researchers and providers use a combination of factors from several theories to guide their programs. Answering the following questions can help determine the most appropriate theories and intervention for a particular community: Which communities/populations are targeted for services? What are the specific behaviors that put them at risk for HIV/AIDS? What are the factors that impact risk-taking behaviors? Which factors are the most important and can be realistically addressed? What theory(ies) or model(s) best address the identified factors? What kind of interventions can best address the above factors?
Theories and models relevant to HIV prevention and education programs reviewed here include: Health Belief Model Theory of Reasoned Action Stages of Change Model/Transtheoretical Model Social Cognitive Learning Theory Harm Reduction Model Behavioral Ecological Model Diffusion of Innovation Theory Community Mobilization Theory Social Disorganization Theory Theory of Gender and Power Environmental Prevention Model
For each theory and model presented, suggestions on how to set up an intervention as well as examples are included. Health Belief Model One of the oldest theories of behavioral health, the health belief model, is the foundation for many behavioral change programs. Also called Information Awareness Theory, this model is the basic knowledge-benefits-cost model. It states: When someone receives information about a health risk, then learns how to avoid this risk, he/she will weigh the cost of the risk behavior as a cue to action, which motivates changing behavior to
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avoid risk and harm. The individual must believe that he/she is at risk. The interaction of other social, cultural, interpersonal and cognitive or skill-issues compound human motivation and behavior. Therefore, information and awareness alone have limited impact on HIV risk behavior, just as they have not been effective by themselves for other prevention issues like smoking, wearing seat belts, drunk driving, teen pregnancy and prevention of other STDs. In fact, for some individuals, the information may create cognitive dissonance and anxiety, which could interfere with behavior change if not addressed. Programs can use the health belief model to set up interventions in the following way: Conduct a Health Communication Public Information (HCPI) intervention by having a booth at a health fair or public event. Conduct Targeted Prevention Activities (TPAs) to disseminate information about HIV/AIDS transmission. Example: A homeless youth understands that multiple sex partners may expose him to HIV but continues to have multiple sex partners because he engages in survival sex to acquire food and shelter. As he continues to encounter safer-sex messages through health fairs and targeted prevention activities, he chooses to reduce his number of sexual partners. Theory of Reasoned Action This theory posits there is a relationship between attitudes, social norms, intention and behavior change. Attitude refers to what someone believes regarding a certain behavior or behavior change. Social norms are the perception of whether ones peers are motivated to engage in or value the behavior. Intentions, or the strength of the planned decision to change behavior, are a function of both personal attitudes and social norms. By understanding an individuals attitudes and the social norms he/she exists in, prevention programs can successfully target these areas with the goal of increasing the individuals strength of intention toward the new behavior (Fishbein, Middlestadt, & Hitchcock, 1994). A weakness in this model can be that intention alone does not guarantee behavior change. Even when strong intentions are built, individuals should be prepared for situations where the new behavior may be difficult to complete. For example, when under the influence of substances, when in a domestic violence situation, as a result of loneliness/depression or a strong desire to please others. Programs can use the theory of reasoned action to set up interventions in the following way: Create linkages in styles of thinking - what the individual thinks (attitude), what he/she perceives his/her peers think (social norms) and how they all feel toward the new behavior regarding its worthiness (strength of intention). Find ways to promote positive attitudes toward new behavior. Find ways to increase perception of how important others (peer norms) value the new behavior.
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Build beliefs that new behavior is beneficial and can lead to a long-term safer outcome. Find ways to down play loss/cost that results from new behavior (i.e. that condoms reduce sexual pleasure).
Example: A gay man believes that using a condom will prevent HIV transmission. His friends also believe that using condoms will prevent HIV transmission. This is reinforced by public service announcements that provide positive images and promote condom use. The gay man feels that his decision to use condoms is correct because it is accepted by his peers and by the gay community. Stages of Change Model/Transtheoretical Model This theory suggests that behavior change is seen as a series of stages. The five stages are pre-contemplation, contemplation, preparation, action and maintenance. Individuals and groups move through stages when incorporating new behaviors into their lives. The model directs attention to choosing interventions which are appropriate to the stage of the target population and is often the stage of pre-contemplation of the new, desired behavior. STAGES OF CHANGE MODEL COMPONENTS Pre-contemplation A person in this stage has no intention to change behavior in the foreseeable future, is unaware of the risk or denies the consequences of risky behavior. A person is aware that a problem exists, is seriously thinking about overcoming it but has not yet made a commitment to take action. A person intends to take action in the near future and may have taken some inconsistent action in the recent past. A person modifies his/her behavior, experiences, or environment to overcome his/her problems; the behavior change is relatively recent. A person works to prevent relapse and maintain the behavior change over an extended period of time.
Contemplation Preparation Action Maintenance
Programs can use the stages of change model to set up interventions in the following ways: Understand in depth the cultural/social issues of the target population before creating any intervention. Creatively break the new target behavior into precursor steps. These often involve the slow shaping of new ideas added to existing attitudes and beliefs. Precursor steps also slowly introduce new behaviors within the context of accepted behaviors and rituals.
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Create interventions that build trust and establish a rapport between educators, key community leaders and members and slowly introduce precursor steps to new target behavior. Create social events with social interventions that shape new beliefs and slowly add the new target behavior over time.
Example: A crystal meth user begins to believe that her drug use is creating health problems in her life. She tries to abstain from using meth for a week but is not able to do so because she is not as productive and does not feel as good. She reverts to believing that meth is not a problem. Through public service announcements and outreach worker contacts, she again believes meth is a problem and tries to quit. After failing several times, she enrolls in a substance abuse treatment program. After the treatment program, she attends support groups to help her not use. Social Cognitive Learning Theory This model has strong roots in learning and emphasizes the strong relationship between attitudes and beliefs that new behavior will lead to a positive outcome and a persons belief in his/her own ability to perform the new behavior whenever necessary. This model works well in conjunction with other models, especially the theory of reasoned action and stages of change models. All three of these models establish that attitudes and social norms interact to form an individuals strength of intention toward a new behavior. Once an individual has acquired the attitude and intention to engage in new riskreducing behavior, this behavior must be incorporated into their everyday living situation. This is often a social, interactive function. Here, social cognitive learning theory encourages a composite of interventions that help an individual adjust to social situations and social environments. This is often done by teaching communication skills and helping participants understand the complexity of social demands, peer dynamics and cultural influences. This theory is more expansive than the others in that it asserts prevention requires social skills. Interventions build a sense of self-efficacy (confidence) that skills can be applied effectively whenever needed. Communication skills are targeted, especially the negotiation of the new behavior with significant others or groups. This builds maintenance of these behaviors and increases intentions, motivations and beliefs toward a new behavior and adds to building new social norms. Programs can use the social cognitive learning theory to set up interventions in the following ways: Teach and practice basic social skills required for new behavior. Help people better adapt socially to the changes they are intending to perform. Use role-plays that require the practice of social-communication skills in order to gradually build mastery of skills. Create interventions where clients can practice dealing with resistance from others in the social environment.
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Help foster a sense of confidence in skills to build increased self-efficacy. Build maintenance interventions into program curricula.
Example: A gay man believes that using a condom will prevent HIV transmission. He finds it difficult to consistently use condoms because his sexual partners tell him that condoms reduce their sexual pleasure. He attends groups where he is able to learn skills that will help him consistently implement safer sex practices including regular condom use. Harm Reduction Model The harm reduction model posits how to reduce health, social and economic harms to individuals and communities. Harm reduction is non-directive and involves an exchange of ideas between the client and the service provider to determine appropriate clientcentered goals. This model has been implemented with substance abuse and is also effective with individuals that are having risky sex. Interventions based on the harm reduction approach are implemented without moral judgment. Harm reduction neither condemns nor supports the use of drugs or behaviors that put individuals at risk but utilizes the stages of change. The focus is on the individual who is engaging in the behavior and the possible harm associated with it. Individuals who are not yet able to abstain from substance use or engaging in risky behaviors may be receptive to this model. Programs can use the harm reduction model to set up interventions in the following ways: Educate injection drug user of benefits of using clean injection equipment to reduce the risk of disease transmission. Provide instruction on the use and cleaning of injection equipment to reduce the frequency of abscesses. Discuss tips on how to moderate or reduce substance use. Encourage use of condoms to reduce the transmission of disease. Provide opportunities to participate in support groups with peers. Example: A transgender commercial sex worker who also injects hormones is enrolled in Comprehensive Risk Counseling and Services (CRCS). During her counseling sessions, she learns how to protect herself from diseases by using clean injection equipment and condoms. Behavioral Ecological Model This model takes into consideration the biological, social and physical environment in which the behavior takes place. Behavior does not occur in a vacuum; therefore, in order to understand and change behavior, it is necessary to manipulate variables at multiple levels. Behavior is influenced by previously experienced contingencies for similar or related behaviors (i.e. positive contingencies increase probability and negative contingencies decrease probability), cultural norms affect behaviors (i.e. members of a culture transmit consistent contingencies) and laws and regulations generate cascading contingencies (i.e. social pressure against tobacco consumption).
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Programs can use the behavioral ecological model to set up interventions in the following ways: Offer groups to help individuals build a social network of like-minded people regarding alcohol and/or drug consumption. Initiate a social marketing campaign to inform the community of the potential dangers of excessive alcohol and or drug consumption. Work with venue owners and employers to prevent serving their patrons too much alcohol. Example: A gay man uses alcohol to ease his anxiety about meeting other men, which has caused him to drink heavily on many occasions. Due to regulations regarding serving intoxicated individuals, bartenders have denied him service. These experiences, coupled with social marketing images in his neighborhood that depict the increase in HIV risk when under the influence of alcohol, result in him seeking help through a counseling program. This program provides one-on-one sessions as well as group sessions that help him decrease his drinking. Diffusion of Innovation Theory This theory focuses on the practice of spreading a new concept, idea or behavior throughout a social system in a person-to-person fashion. There are four primary components to this theory: 1. The target population perceives the innovation as new. 2. Channels of communication exist to disseminate the innovation. 3. There is sufficient time or a process for the innovation to reach population members. 4. A social network exists that connects the members of the target population. Programs can use the diffusion of innovation theory components to set up interventions in the following ways: Create a core group of influential individuals who will help craft messages. Utilize a core groups existing social networks to disseminate HIV prevention information. Example: Through TPAs, individuals have been identified and asked to meet to discuss HIV prevention ideas. These ideas are then talked about in their social networks. The HIV prevention ideas are accepted and reinforced. Ongoing groups fashioned as social events are also used to reinforce HIV prevention messages. Community Mobilization Theory This theory describes how social movements, initiated by members of a culture, can change that cultures institutions, experiences or characteristics. Established and emerging local leaders usually initiate and maintain social movements with the support of recognized community organizations. Once the issues are fully understood by the community members, solutions are jointly proposed, agreed and acted upon. This seeks to promote health by increasing peoples feelings of power and control over their lives.
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Programs can use the community mobilization theory to set up interventions in the following ways: Work with existing community based organizations (CBOs) to hold community forums or conferences to address the needs of the community. Create a set of common goals that members of the community can support. Continue to work with organizations to empower community members to implement change and reduce risk of HIV. Example: The transgender community lacks adequate medical resources, which can lead to unsupervised hormone use. The community members advocate to expand medical services to include hormone treatment. Social Disorganization Theory This theory states that where social institutions, norms and values are no longer functioning, high rates of violence, drug abuse, poverty and disease occur. Programs can use the social disorganization theory to set up interventions in the following ways: Work with existing CBOs to address health disparities in low-income areas. Work with community members to advocate for change. Example: An African American community has limited health care or financial resources in their neighborhood. Working with community organizations, they are able to include HIV testing as a routine part of health care. Theory of Gender and Power This theory views the differences in labor, power dynamics and relationship investment between women and men as structures that can produce inequalities for women and increase womens risk and vulnerability to HIV. Programs can use the theory of gender and power to set up interventions in the following ways: Provide groups to develop communication skills between people of different genders. Offer individual-level interventions (ILIs) to develop safe-sex negotiation skills. Refer individuals to resources that deal with specific issues (i.e. domestic violence). Example: A Latina is not able to ask her male partner to use a condom because of her fear that her partner will think she is being unfaithful. She is educated in a group through role playing on negotiation skills building to ask her partner to use condoms.
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Environmental Prevention Model Environmental Prevention aims to change social norms and behavior by addressing the community conditions that sustain public health and safety problems. Environmental Prevention is an approach made up of five strategies that, when integrated, result in an effective environmental prevention campaign. These five strategies include: 1. Data and Research: Identifies the magnitude of the problem and possible solutions, guides intervention planning throughout the campaign, gives credibility to the process, guides the process, evaluates its effectiveness and demonstrates change that occurs. 2. Community Organizing: Brings together different key sectors of the community with the expertise necessary to define, support and advance the change process. 3. Policy Development: Policy provides direction to develop a campaign strategy based on data as well as community input to create institutional, community and cultural change. 4. Media Advocacy: Media advocacy is the strategic use of news making as a resource to advance a social or public policy initiative. It is also the number one tool to foster change in a communitys norms and behavior. 5. Enforcement: Local, state and federal law enforcement officials, agencies and the judicial system develop essential partnerships and efforts that are supported by the community to ensure implementation of policies aimed to reduce/prevent problems. Programs can utilize the environmental prevention model to set up interventions in the following ways: Utilize data and research to inform social marketing and community planning. Intentionally organize to get community support for prevention activities. Take a policy approach to address business policies in venues where high-risk activities occur. Employ media advocacy to engage the community and advance policy goals. Understand laws at all levels to establish collaborations with appropriate prevention partners. Example: The HIV, STD and Hepatitis Branch of Public Health Services (HSHB) conducted an assessment of the Lesbian, Gay, Bisexual and Transgender Community to determine the readiness of the community to address substance abuse as a risk factor for HIV. The next steps would be to hold a forum to share findings from the assessment with the community, partner with business owners to implement policies supported by the community, encourage and provide technical assistance to community members to write articles in newspapers in support of policies, be interviewed by the news media and/or be aware of any laws that could support efforts while being cautious not to alienate important segments of the community.
110
APPENDIX D HIV EDUCATION AND PREVENTION RESOURCE INVENTORY
111
112
APPENDIX D HIV EDUCATION PREVENTION RESOURCE INVENTORY SAN DIEGO COUNTY HIV EDUCATION AND PREVENTION RESOURCE INVENTORY
NOTE: Legend of acronyms and definition of interventions can be found on pages 123-124. Last Updated 1/15/09 prior to budget cuts resulting in a 63 percent decrease in HIV education and prevention direct services. Effective July 1, 2009, CRCS became an optional intervention. HIV Education and Prevention Services Provider
Type of Service
Intervention
HIV Testing
Target Population
Target Behavioral Risk Group
Funding Sources
Type of Program(s)
Region
FHCSD HIV Services
TPA GLI ILI CRCS PS HCPI
DEBIs Cara A Cara mPowerment Brothers United 3MV SISTA Healthy Relationships EBI CDCynergy
Yes
African American and Latino MSM and all ethnic groups
HIV positive MSM IDU MSM/IDU Sex partner of MSM Sex partner of IDU Women at high risk Youth at high risk Transgender HIV positive MSM IDU MSM/IDU Sex partners of MSM Sex partners of IDU Women at high risk Youth at high risk Transgender
CDC HHSA-HSHB-C&T HHSA-HSHB-HCT HHSA-HSHB-MAI HHSA-HSHB-E&P City of San Diego Private foundations: Alliance Healthcare CA Endowment Tides Foundation SD HIV Funding Collaborative
HIV/AIDS service organization within a community clinic
Central East North Central South
The LGBT Center
GLI ILI CRCS HCPI PS
EBI Positive Action Sexual Health Groups
Yes
Latino and all LGBT
HHSA-HSHB-E&P (subcontractor of FHCSD) Private donations
CBO with non HIV/AIDS specific services
Central
113
SAN DIEGO COUNTY HIV EDUCATION AND PREVENTION RESOURCE INVENTORY

HIV Education and Prevention Services Provider Type of Service Intervention HIV Testing Target Population Target Behavioral Risk Group Funding Sources Type of Program(s) Region
San Diego Youth Services, HIV Services
TPA GLI ILI CRCS HCPI PS
EBI Yo Peeps (locally developed group intervention for youth) LGBT Youth Groups
No
All ethnic groups
Youth at high risk
HHSA-BH-ADS City of San Diego HHSA-HSHB-E&P
Multi-service agency with HIV/AIDS services
Central North Central East
Stepping Stone Positive Support Services
EBI First Things First Positive Support Services
No
HIV positive and all ethnic groups
San Ysidro Health Center
EBI Positivo/a Activo/a y Vivo/a locally Yes developed Prevention with Positives group intervention
Latinos and all ethnic groups
HIV positive MSM IDU MSM/IDU Sex partner of MSM Sex partner of IDU Women at high risk Youth at high risk Transgender HIV positive MSM IDU MSM/IDU Sex partner of MSM Sex partner of IDU Women at high risk Youth at high risk Transgender
HHSA-ADS HHSA-HSHB-E&P (subcontractor of FHCSD)
Harm reduction, substance abuse treatment and HIV services
Central North Central East
HHSA-HSHB-E&P HHSA-HSHB-C&T HHSA-HSHB-HCT HHSA-HSHB-MAI CDC (subcontractor of FHCSD) HRSA-SPNS SD HIV Funding Collaborative
Community clinic with HIV/AIDS specific services
Central South
114
SAN DIEGO COUNTY HIV EDUCATION AND PREVENTION RESOURCE INVENTORY

HIV Education and Prevention Services Provider Type of Service Intervention HIV Testing Target Population Target Behavioral Risk Group HIV positive MSM IDU MSM/IDU Sex partner of MSM Sex partner of IDU Women at high risk Youth at high risk Transgender Funding Sources Type of Program(s) Region
Vista Community Clinic
DEBI mPowerment Healthy Relationships EBI HIV positive Support Groups Health Education
Yes
All ethnic groups
HHSA-HSHB-E&P HHSA-HSHB-C&T HHSA-HSHB-EIP HHSA-HSHB-HCT CDPH/OA SD HIV Funding Collaborative Office of Minority Health
Community clinic with HIV/AIDS specific services
North Coastal North Inland
115
SAN DIEGO COUNTY HIV EDUCATION AND PREVENTION RESOURCE INVENTORY HIV Specific Service Providers
HIV Prevention Services Provider
(not funded by HSHB)
Type of Service
Intervention
HIV Testing
Target Population
Target Behavioral Risk Group HIV positive MSM IDU MSM/IDU Sex partner of MSM Sex partner of IDU Youth at high risk Transgender HIV positive MSM IDU MSM/IDU Sex partner of MSM Sex partner of IDU Women at high risk Youth at high risk Transgender MSM IDU MSM/IDU Women at high risk
Funding Sources
Type of Program(s)
Region
Being Alive, San Diego
GLI HCPI
EBI New Beginnings HIV Support Groups Peer Advocacy
No
HIV positive with focus on MSM
Private donation
HIV/AIDS service organization
Central
Bienestar
TPA GLI ILI CRCS PS
DEBI mPowerment SISTA
Yes
Latino
CDC
CBO with HIV specific services
Central East South
Chicano Federation
TPA ILI
EBI
No
Latino
CDC OA
Community based organization (not HIV/AIDS specific)
All
116
SAN DIEGO COUNTY HIV EDUCATION AND PREVENTION RESOURCE INVENTORY HIV Specific Service Providers (continued)
Type of Service
Intervention
HIV Testing
Target Population
Target Behavioral Risk Group HIV positive MSM IDU MSM/IDU Sex partner of MSM Sex partner of IDU Women at high risk Youth at high risk Transgender HIV positive Sex partner of IDU Sex partner of MSM Women at high risk Youth at high risk HIV positive HIV positive MSM IDU MSM/IDU Sex partner of MSM Sex partner of IDU Women at high risk
Funding Sources
Type of Program(s)
Region
Christ Church of San Diego, CA Inc
TPA ILI GLI HCPI
Health Education
No
African American
Member Funded
Community based organization (not HIV/AIDS specific)
Central
Christie's Place
TPA GLI PS HCPI TPA ILI HCPI PS
EBI HIV Support Groups (English and Spanish) EBI Health Education
No
HIV positive women and families
General agency funds raised through donations
HIV/AIDS service organization
Central
Comprehensive Health Center
Yes
All ethnic groups
HRSA
Health Clinic
Central
The Center for Social Support and Education (CSSE)
TPA GLI ILI HCPI
EBI
Yes
African American
CBO with HIV specific services
Central
117
Type of Service
Intervention
HIV Testing
Target Population
Target Behavioral Risk Group HIV positive MSM IDU MSM/IDU Sex partners of MSM Sex partners of IDU Women at high risk Youth at high risk Transgender HIV positive MSM IDU MSM/IDU Sex partners MSM Sex partners IDU Women HIV positive MSM IDU MSM/IDU Sex partner of MSM Sex partner of IDU Women at high risk Youth at high risk Transgender
Funding Sources
Type of Program(s) CBO with non HIV/AIDSspecific services Focus: Substance abusers; HIV positive or at high risk Multi-service agency with HIV/AIDS services Hospital Primary Care
Region
Jewish Family Service
TPA ILI HCPI PS
EBI Psychosocial Therapy Behavioral Intervention Services
Yes
All ethnic groups AOD treatment and HIV positive
HSHA-BH-AOD HRSA Private foundation
Central East South North Inland North Costal
Kaiser Permanente
TPA ILI CRCS PS HCPI
Health Education
Yes
All ethnic groups
Private insurance Medical
All
Neighborhood Healthcare
TPA GLI ILI HCPI
EBI Health Education
Yes
African American
HHSA-BH-MHS
Health Clinic
Central North Inland
118
Type of Service
Intervention
HIV Testing
Target Population
Target Behavioral Risk Group HIV positive MSM IDU MSM/IDU Sex partner of MSM Sex partner of IDU Women at high risk Youth at high risk Transgender HIV positive MSM IDU MSM/IDU Sex partners of MSM Sex Partners of IDU
Funding Sources
Type of Program(s)
Region
North County Health Services
GLI ILI HCPI PS
EBI HIV Support Groups Case Management
Yes
All ethnic groups
HHSA-HSHB-C&T HHSA-HSHB-HCT CDPH/OA
Health Clinic CBO
North Coastal North Inland
Owen Clinic, UCSD Medical Center
ILI PS
Health Education
No
All ethnic groups
UCSD HHSA-HSHB-C&T HRSA-SPNS
University Hospital
All
San Diego American Indian Health Center, Inc.
TPA GLI ILI HCPI
EBI
Yes
HIV positive and Native Americans
HIV positive MSM MSM/IDU Women at high risk Youth at high risk
HHSA-HSHBRWTMA HHSA-CMS HHSA-BH-MHS Indian Health Services Medi-cal Medicare Private Insurance VA Private Foundation
Multi-service agency with HIV/AIDS services
Central South East North Central
119
Type of Service ILI PS TPA
Intervention
HIV Testing Yes No
Target Population All ethnic groups Gay Men of all ethnic groups HIV positive and all ethnic groups
Target Behavioral Risk Group HIV positive Youth HIV positive MSM HIV positive MSM IDU MSM/IDU Sex partners of MSM Sex partners of IDU Meth Using HIV positive MSM IDU MSM/IDU Sex partners of MSM Sex partners of IDU Youth at high risk Transgender HIV positive MSM Sex partners of MSM Women at high risk Youth at high risk
Funding Sources Set fee Foundation Private
Type of Program(s) College health center Social/ politician organization University HIV/AIDS research facility
Region
SDSU Student Health Services Sisters of Perpetual Indulgence
Health Education EBI Community Outreach
Central Central
UCSD Early Intervention Program
ILI
Yes
CDPH/OA
All
UCSD MUMSM (Meth Using MSM) The Edge
TPA ILI HCPI
EBI
No
Latino and all ethnic groups
NIH
University Research
Central
UCSD Mother, Child and Adolescent HIV Program
TPA GLI ILI HCPI PS
Health Education Health Promotion Pre-exposure Prophylaxis Youth Council
Yes
HIV positive women, children and adolescents in all ethnic groups
HRSA RWTEA Part D
University HIV/AIDS services
All
120
SAN DIEGO COUNTY HIV EDUCATION AND PREVENTION RESOURCE INVENTORY Family Planning and Other Social Services
Type of Service GLI ILI
Intervention
HIV Testing No
Target Population All ethnic groups All ethnic groups with focus on Latino All ethnic groups
Target Behavioral Risk Group Women at high risk IDU Sex partners of IDU Women at high risk IDU MSM/IDU Sex partners MSM Sex partners IDU Women at high risk Youth at high risk Transgender Youth at high risk
Funding Sources Self pay Private Foundation CDBG HCD HHSA-BH-MHS VA Foundation Private
Type of Program(s) Housing service provider Multi-service agency with no HIV/AIDS specific services Reproductive Health
Region
Big Sister League of San Diego, Inc Interfaith Community Services Planned Parenthood
Health Education
All North Coastal North Inland All
HCPI TPA ILI HCPI
Health Education
No
Health Education Family Planning
Yes
San Diego Family Care
TPA GLI ILI HCPI
Health Education Family Planning
Yes
All ethnic groups
Office of Population Affairs (OPA)
Health Clinic
Central North Central
Operation Samahan Vista Hill Parent Care
TPA GLI HCPI GLI ILI
Health Education Family Planning Health Education
Yes
Youth and all ethnic groups All ethnic groups
CA HHSA-BH-ADS Donors Sliding scale fee
Teen pregnancy prevention Substance Abuse Tx
All East North Inland
No
Women at risk
121
122
Legend of Resource Inventory Acronyms Service Provider Family Health Centers of San Diego Lesbian, Gay, Bi-sexual and Transgender University of California, San Diego San Diego State University Center for Social Support and Education Type of Service Targeted Prevention Activity Group Level Intervention Individual Level Intervention Comprehensive Risk Counseling and Services Partner Counseling and Referral Service Health Communication Public Information Type of Intervention Many Men, Many Voices Diffusion of Effective Behavioral Intervention CDC designation Effective Behavioral Intervention Sisters Informing Sisters about Topics on AIDS Target Behavioral Risk Group Injection Drug User Men who have Sex with Men Both MSM and IDU Funding Source Alcohol and Drug Services HIV Care and Treatment Center for Disease Control and Prevention County of San Diego Community Development Block Grant California Department of Public Health, Office of AIDS County Mental Health Services County Medical Services HIV Education and Prevention Early Intervention Program HIV Counseling and Testing County of San Diego Housing and Community Development Grant Health and Human Service Administration Health Resources and Services Administration HIV, STD and Hepatitis Branch of Public Health Minority AIDS Initiative Mental Health Service Administration National Institute of Health Office of Population Affairs Ryan White Treatment Modernization Act 2006 Substance Abuse and Mental Health Services Administration Special Project of National Significance University of California, San Diego Veterans Administration Education and Prevention Evaluation and Consultants Coalition of Latino AIDS Service Providers San Diego Association of Governments
FHCSD LGBT UCSD SDSU CSSE TPA GLI ILI CRCS PCRS HCPI 3MV DEBI EBI SISTA IDU MSM MSM/IDU ADS C&T CDC CDBG CDPH/OA MHS CMS E&P EIP HCT HCD HHSA HRSA HSHB MAI MHSA NIH OPA RWTMA SAMHSA SPNS UCSD VA CLASP SANDAG
123
Intervention Definitions TPA - Outreach or Targeted Prevention Activities: Face-to-face contact through outreach in areas where individuals at highest risk for acquiring or transmitting HIV congregate. May include referrals to HIV Counseling and Testing and other support services as well as distribution of materials to prevent HIV such as condoms, bleach and educational materials. GLI - Groups or Group Level Interventions: Groups with individuals at highest risk for acquiring or transmitting HIV that provide information, education, support and skills building to prevent the acquisition or transmission of HIV. ILI - Individual Risk Counseling or Individual Level Interventions: Short term health education and risk reduction counseling provided to one client at a time for one to three HIV prevention sessions usually lasting more than 20 minutes. Does not include outreach or HIV counseling and testing. CRCS - Comprehensive Risk Counseling and Services (formerly called Prevention Case Management): Intensive, ongoing and individualized health education and risk reduction counseling. A client centered activity for clients with multiple, complex problems and risk reduction needs. This intervention is more intensive than individual level interventions with multiple sessions specifically focusing on the reduction of risk for acquiring or transmitting HIV. PS - Partner Services: Disclosure assistance to help HIV positive individuals disclose their HIV status in any of the following three situations: 1) on their own (self-disclosure), 2) in the presence of a partner and counselor (dual disclosure) or 3) referral for third party notification in which the County of San Diego anonymously notifies partners of potential exposure to HIV. HCPI - Presentations and Events: HIV prevention health information provided at community events, health fairs and presentations in detention facilities. Social Marketing: HIV prevention health information provided to the public through social marketing and behavior change campaigns.
124
APPENDIX E METH STRATEGIES ORGANIZATIONAL CHART
125
126
APPENDIX E METH STRATEGIES ORGANIZATIONAL CHART The Meth Strategies Organizational Chart and accompanying Meth Services Resource Directory (see Appendix F on page 139) were produced by the HIV Prevention Community Planning Group and Family Health Centers of San Diego. They are working documents and attempt to but may not be inclusive of all the activities related to reducing the harms of methamphetamine in San Diego County. The Meth Strategies Categories of Responses are listed on page 129 followed by a detailed look at each category of responses to the harms caused by methamphetamine. The categories and directory provided were last updated in November 2009. The strategies contained in this document are limited to the knowledge of those who contributed. Each box shows primary strategies to address harm caused by meth, and there may be additional functions and strategies not listed. Feedback on sections for which you have knowledge is welcome. Please contact Jae Egan at 619-692-8369 or jeffrey.egan@sdcounty.ca.gov.
127
128
APPENDIX E METH STRATEGIES ORGANIZATIONAL CHART
CATEGORIES OF RESPONSES TO THE HARMS CAUSED BY METHAMPHETAMINE
Behavioral Health Services
Planning and Policy
Business Organizing and Community Strategies
Enforcement
Data and Research
Social and Medical Services
Media
Education
129
Behavioral Health Services

Mental Health Services Mental Health
Alcohol and Drug Services
Detoxification
Residential Treatment
Outpatient Treatment
Substance Abuse Prevention and Treatment (HIV Set Aside)
HIV, STD and Hepatitis Branch of Public Health
Jewish Family Service (JFS)
HIV Care and Treatment
Stepping Stone of San Diego
Gifford Clinic UCSD
The San Diego LGBT Center
AIDS Case Management
Minority AIDS Initiative
Other BHS
JFS Getting Off
SD Access and Crisis Hotline
Discovering Sexual Health
Positive Reinforcement Opportunity Project
130
Planning and Policy

Planning
HIV Prevention Community Planning Group
Prevention Strategies and Evaluation Meth Services Planning Group Meth Strike Force ADS Meth Prevention Initiative East County Coalition for Meth Solutions California HIV Planning Group Policy
ADS Meth Prevention Initiative
131
Business Organizing and Community Strategies

Business Organizing
Community Events and Forums
Tavern Guild
Community Strategies
Meth Strike Force/Meth Prevention Initiative (ADS)
Neighborhood Safety Work Group
Policy and Business Practice Development (ADSMPI)
LGBT Leadership Council
132
Enforcement
State and Federal

Federal Drug Enforcement Administration
Narcotics Task Force
San Diego Law Enforcement Coordination Center (SD-LECC)

California Border Alliance Group High Intensity Drug Trafficking Area (HIDTA)
Meth Strike Force Stop Meth Associated Crime (SMAC)
Bureau of Narcotics Enforcement Local Law Enforcement
San Diego Police Department Probation and Parole Sheriffs Office
133
Social and Medical Services
Support Services
Safe Point San Diego Steps to Change
HIV Support Services

UCSD Programs for HIV Early Intervention Program Mother, Child and Adolescent HIV Program
UCSD Meth Related Research Center
HNRC HIV Neurobehavioral Research Center
Support Groups
Jewish Family Service Talking About Tina The LGBT Center So You Want to Get Off Crystal Meth Anonymous 12 Step
Positive Reinforcement Opportunity Project (PROP)
Child Welfare Services
Drug Endangered Children
Child Welfare
134
Data and Research
UCSD
The EDGE Project
Supporting Positive Living and Sexual Health (SPLASH)
Fast Lane SANDAG

MTP: HEARTT-Meth Treatment Project: Helping Every Addict Recover Through Treatment
Substance Abuse Monitoring (SAM) High Risk Behavior Change Campaign Evaluation Meth Strike Force
Meth Strike Force Meth Report Card

HIV Substance Abuse and Prevention Treatment Projects (HIV Set Aside)
Meth and HIV in San Diego County: A Provider and Community Assessment
San Diego County HIV Risk Behavior and HIV Prevention Services Report
Meth Strike Force/ Meth Prevention
LGBT Community Readiness Assessment to Address Substance Use as a Risk Factor for HIV
Meth Strike Force/ Meth 135 Prevention Initiative (ADS)
Media
Social Marketing
Know Crystal
Crystal Mess
Me Not Meth
Meth Free Life
Media Advocacy
ADS Countywide Media Advocacy
136
Education
HIV Education and Prevention Programs (see Appendix M for brochure)
Community Forums
Meth Solutions Prevention Video
MSF Education Committee
Sheriff Crime Prevention
137
138
APPENDIX F METH RESOURCES DIRECTORY
139
140
APPENDIX F METH RESOURCES DIRECTORY

NOTE: This resource list was produced by the HIV Prevention Community Planning Group and Family Health Centers of San Diego. It is a working document and attempts to but may not be inclusive of all the activities related to reducing the harms of methamphetamine in San Diego County. The resources contained in this document are limited to the knowledge of those who contributed. If you would like to provide detailed information about a specific service or agency on this document, please contact Jae Egan at 619-692-8369 or jeffrey.egan@sdcounty.ca.gov.
BEHAVIORAL HEALTH SERVICES

Mental Health Services Mental Health Services Alcohol and Drug Services Detoxification Website/Links http://sandiego.networkofcare.org/mh Contact Information 619-563-2700 Information Offers a wide variety of treatment, rehabilitation and recovery services to help people who are experiencing persistent and severe mental illness or a mental health crisis. Information A list of a variety of detoxification treatment services. All services are provided via contract with local service providers. A list of residential treatment sites throughout the county, grouped by geographic location, available. A list of non-residential treatment sites throughout the county, grouped by geographic location, available. HIV education and prevention, counseling and testing services, STD clinical services, HIV/AIDS care and treatment services, AIDS drug assistance program, disease reporting information, disease fact sheets and resources, reports and statistics, Partner Services, AIDS Case Management, HIV and STD prevention unit A non-profit organization providing individual and group services to people infected with or at high risk of contracting HIV who struggle with managing their HIV health and recovery from substance abuse. Services include substance abuse counseling, HIV education, referrals for HIV positive individuals and mental health services for HIV positive or high-risk clients with co-occurring mental health and substance abuse problems. 141
Website/Links http://www.co.sandiego.ca.us/hhsa/programs/bhs/alcohol_drug_servic es/adult_treatment_services_detox.html http://www.co.sandiego.ca.us/hhsa/programs/bhs/alcohol_drug_servic es/adult_treatment_services_residential.html http://www.co.sandiego.ca.us/hhsa/programs/bhs/alcohol_drug_servic es/adult_treatment_services_nonresidential.html
Contact Information ADS: 619-584-5007 ADS: 619-584-5007 ADS: 619-584-5007
Residential Treatment
Outpatient Treatment
HIV,STD and Hepatitis Branch of Public Health
http://www.co.sandiego.ca.us/hhsa/programs/phs/hiv_std_hepatitis_br anch/index.html
619-293-4700
Jewish Family Service
http://www.jfssd.org/hiv
858-637-3020
BEHAVIORAL HEALTH SERVICES (Continued)

HIV Care and Treatment Website/Links Contact Information General Number: 619-584-4010 Client Services Manager Cece Swanson: 619-295-3995 x125 General Number: 619-299-3510 Information & Appointments: 619-497-6673 General Number: 619-692-2077 Hillcrest Youth Center: 619-497-2920 Latino Services: 692-2077 x116 Tim Smith: 619-293-4725 Information A non-profit, outpatient and residential alcohol and drug recovery agency that is based upon a social model of recovery incorporating the Twelve Steps Program. Specific programs target HIV positive, LGBT and IDU communities. The UCSD Co-Occurring Disorders (COD) Integrated Treatment and Recovery provides intensive integrated services for individuals with co-occurring substance abuse and other mental disorders.
Stepping Stone of San Diego
www.steppingstonesd.org
Gifford Clinic UCSD
http://psychiatry.ucsd.edu/adultOutpatientPatient.ht ml
The San Diego LGBT Community Center
www.thecentersd.org
The LGBT Center enhances and sustains the health and well-being of the lesbian, gay, bisexual, transgender and HIV communities by providing various activities, programs and services. A program which offers inpatient treatment to HIV positive individuals requesting treatment for addiction to alcohol and drugs. Provides free comprehensive services for people of color who are HIV positive and interested in receiving mental health and or substance abuse services. Services offered range from counseling/therapy, substance abuse treatment, counseling, case management, client advocacy and support groups.
AIDS Case Management
http://www.sdcounty.ca.gov/hhsa/programs/phs/hiv_ std_hepatitis_branch/aids_case_management.html
Minority AIDS Initiative
N/A
Harold Cooks: 619-876-4464 haroldc@fhcsd.org
142
BEHAVIORAL HEALTH SERVICES (Continued)

Other BHS Getting Off www.jfssd.org/HIV Website/Links Contact Information Jewish Family Service: 858-637-3020 Hotline: 1-800-479-3339 Information A 24 session, evidence-based, intensive behavioral treatment intervention for gay and bisexual men who use methamphetamine. A hotline that provides referrals for mental health and substance abuse programs throughout San Diego County. The hotline is operated 24/7. An intervention designed to help Stepping Stone participants evaluate their own risk of drug relapse due to unaddressed high-risk sexual behaviors and develop safer, low-risk sexual behaviors that will not likely contribute to drug or alcohol relapse. Program offered incentives for providing meth free urine samples three times a week. The program ended September 2009 and is no longer enrolling new clients.
San Diego Access and Crisis Line
http://www.suicidehotlines.com/california.html
Discovering Sexual Health
http://www.steppingstonesd.org/NewPrograms.html
619-584-4010
Positive Reinforcement Opportunity Project (PROP)
www.fhcsd.org
Debbie Hamilton 619-515-2588 debbieh@fhcsd.org
143
PLANNING AND POLICY

Planning HIV Prevention Community Planning Group Website/Links Contact Information Lori Jones: 619-293-4755 lori.jones@sdcounty.ca.gov Information The mission of the San Diego County HIV Prevention Community Planning Group is to improve health, inclusive of sexual health, through risk reduction activities and prevent new HIV infections in the County. The Prevention Strategies and Evaluation Committee of the HIV Prevention Community Planning Group contributes to the community planning process for HIV education and prevention services in San Diego County. The committee has provided input in the development of the meth services portion of the San Diego County 2008 Health and Social Services Survey and the meth use section of the San Diego County 2008 Health Services Survey for People Living with HIV/AIDS. Please see website for a complete listing of meeting times and locations. A group of community service providers, meeting since 2007 to develop strategies to address the use of methamphetamine among MSM in San Diego. The group has conducted multiple trainings to assist service providers in increasing their capacity to work with active meth users based upon a toolkit available on the internet. Meth-specific community resources are provided as well. A partnership of 70 member organizations and agencies, including local, state and federal representatives from public health, law enforcement, judiciary, education, treatment, prevention and intervention agencies that address county wide methrelated issues.
http://www.sdhivprevention.org/
Prevention Strategies and Evaluation Committee
http://www.sdhivprevention.org/
Dan Uhler: 619-293-4720 daniel.uhler@sdcounty.ca.gov
Meth Services Planning Group
www.crystalmethsolutions.org
Sheri Kirshenbaum: 858-637-3020 sherik@jfssd.org
Meth Strike Force
www.no2meth.org
General Number: 1-877-No-2-Meth Angela Goldberg: 760-749-8792 angelagoldberg@sbcglobal.net
144
PLANNING AND POLICY (Continued)

Planning ADS Meth Prevention Initiative (Logic Model) Website/Links http://www.no2meth.org/docs/2006_MPI_LM_Cur riculum.pdf Contact Information Joe Eberstein jeberstein@publicstrategies.org Susan Caldwell 619-456-9607 scaldwell@publicstrategies.org Information A community change model of San Diego Countys Alcohol and Drug Services used to prevent alcohol and drug problems throughout the region. A community change model of San Diego Countys Alcohol and Drug Services used to prevent alcohol and drug problems throughout the region. A group that provides community perspectives, advice and recommendations to the CDPH/OA in the planning, development and allocation of resources for a comprehensive, client-centered continuum of prevention and care services. A community change model of San Diego Countys Alcohol and Drug Services used to prevent alcohol and drug problems throughout the region.
East County Coalition for Meth Solutions
This project is no longer active
California HIV Planning Group
www.cahivplanninggroup.org
Mary Geary 916-449-5804 mary.geary@cdph.ca.gov
ADS Meth Prevention Initiative (Logic Model)
http://www.no2meth.org/docs/2006_MPI_LM_Cur riculum.pdf
Joe Eberstein jeberstein@publicstrategies.org
145
BUSINESS ORGANIZING AND COMMUNITY STRATEGIES

Business Organizing Community Events and Forums Website/Links Contact Information Renee Sievert: 858-573-2600 x1704 rsievert@mhsinc.org Information An annual multi-cultural resource fair designed to create and increase public awareness of alcohol and drug recovery programs and services available in San Diego County. A group of local LGBT owned bars and restaurant owners that get together to discuss issue around their businesses. It serves as a opportunity to talk about trends in their industry as well as a forum to meet with local officials and law enforcement. Reduces the impacts of methamphetamine in San Diego County to improve children's lives, neighborhood safety and the environment. The Neighborhood Safety Work group and Policy and Business Practice Development Work group are a part of the Meth Prevention Initiative. Reduces alcohol and other drug related activities, especially methamphetamine, in residential neighborhoods by advancing the use of responsible property management policies and procedures. Reduces the harms associated with meth use and/or meth-related activity among highrisk populations through policy enactment and improved business practices. Provides a formal vehicle for community organizations to strategize and create a vision for the future of San Diegos LGBT community, create stronger collaborations and strategize ways to provide leadership development for community organizations.
http://www.recoveryhappens-sandiego.org/
Tavern Guild
N/A
Mike Phillips (Big Mike): 619-807-7324 BM575@bancforce.com
Methamphetamine Strike Force/Methamphetamine Prevention Initiative (ADS) Methamphetamine Strike Force/Methamphetamine Prevention Initiative (ADS) Neighborhood Safety Work Group Methamphetamine Strike Force/Methamphetamine Prevention Initiative (ADS) Policy and Business
www.no2meth.org
Angela Goldberg: 760-749-8792 angelagoldberg@sbcglobal.net
www.no2meth.org
Angela Goldberg: 760-749-8792 angelagoldberg@sbcglobal.net Cyndi Anzalone, Chair San Diego Youth Leadership Partnership: 619-840-3050 cyncam5@yahoo.com
www.no2meth.org
LGBT Leadership Council
http://www.thecentersd.org/communityleadershipcou ncil.php
Patrick Loose: 619-692-2077 ploose@thecentersd.org
146
ENFORCEMENT
State and Federal Federal Drug Enforcement Administration Website/Links Contact Information Information Enforces the controlled substance laws and regulations of the United States. Recommends and supports non-enforcement programs aimed at reducing the availability of illicit controlled substances on the domestic and international markets. Integrates resources and investigative efforts to address the trafficking of controlled substances and drug proceeds being commercially trafficked and/or transported via air and parcel. Provides strategic drug-related intelligence, document and computer exploitation support and training assistance to the drug control, public health, law enforcement and intelligence communities of the United States in order to reduce the adverse effects of drug trafficking, drug abuse and other drug-related criminal activity. SD-LECC is a resource for law enforcement only. It involves coordination and intelligence gathering. Seeks to measurably reduce drug trafficking, thereby reducing the impact of illicit drugs in the nation's southwest border region and other areas of the country. It assists with the coordination of joint initiatives to deter, disrupt and dismantle the most significant drug trafficking organizations and their supporting transportation and money laundering organizations. It also emphasizes efforts against meth manufacturing, precursor supply and abuse. Law enforcement, prevention and treatment professionals, along with community resource agencies, operate a campaign to use media to alert customers and establish safe shredding practices, upgrade mailboxes and secure compliance with laws to remove customer information on receipts.
http://www.usdoj.gov/dea/pubs/states/sandiego.html
San Diego Division: 858-616-4100
Narcotics Task Force
http://ag.ca.gov/bne/content/spectask.php
Airport and Parcel Team: 619-686-8020
San Diego Law Enforcement Coordination Center (SD-LECC)
http://www.usdoj.gov/ndic/pubs23/23933/sources.htm http://www.sdsheriff.net/2008/lesb.html
Steve Lough: 858-495-7248
California Border Alliance Group High Intensity Drug Trafficking Area (HIDTA)
http://www.ncjrs.gov/ondcppubs/publications/enforce/ hidta2001/ca-fs.html
San Diego Region: 619-557-5880
Meth Strike Force- Stop Meth Associated Crime (SMAC)
http://www.no2meth.org/smac.htm
1-877-No2Meth www.No2Meth.org Angela Goldberg: 760-749-8792 angelagoldberg@sbcglobal.net
147
ENFORCEMENT (Continued)
Local Law Enforcement Bureau of Narcotics Enforcement Website/Links http://ag.ca.gov/bne/ Contact Information San Diego Regional Office: 858-268-5300 Narcotics Unit: 619-531-2468 Non-emergency: 619-531-2000 and 858-484-3154 Emergency: 9-1-1 Main: 619-557-5510/6650 Chula Vista: 619-409-5100 El Centro: 760-352-2138 Vista: 760-806-9353 Main: 858-974-2222 Information Targets major drug dealers, violent career criminals, clandestine drug manufacturers and violators of prescription drug laws. Works together in a problem solving partnership with communities, government agencies, private groups and individuals to fight crime and improve the quality of life for the people of San Diego. Serves the Court by investigating and supervising individuals convicted of crimes. The chief law enforcement agency in San Diego County. Provides general law enforcement, detention and court services.
San Diego Police Department
http://www.sandiego.gov/police/
Probation and Parole
http://www.casp.uscourts.gov/
Sheriffs Office
http://www.sdsheriff.net/
148
SOCIAL AND MEDICAL SERVICES

Support Services Website/Links Contact/Information Information Offers comprehensive services to help injection drug users reduce the risk of HIV and hepatitis transmission. Services include individual education, case management, referrals to drug treatment and detoxification and one-for-one syringe exchange. Services are provided from a mobile unit. Services include medical care, treatment and support for people living with HIV/AIDS in San Diego County and who are uninsured or underinsured. Information Provides counseling, risk reduction information, health education, disclosure assistance, case management, primary care and other referrals for people who are newly diagnosed with HIV. Provides a range of services for HIV positive women, children and youth. They provide individual and group therapy, counseling, case management, support and educational groups, peer advocacy and more. Information Supports many HIV/AIDS-related projects and the effects of various co-morbidities such as substance abuse and hepatitis C infection through various ongoing studies.
Safe Point San Diego Steps to Change
http://www.fhcsd.org/services/syringe.cfm
Robert Lewis: 619-515-2586 robertl@fhcsd.org
HIV Support Services UCSD Programs for HIV Positives Early Intervention Program
http://www.sdcounty.ca.gov/hhsa/programs/phs/hiv_st d_hepatitis_branch/hiv_aids_care_and_treatment_ser vices.html Website/Links
619-293-4700
Contact Information UCSD: 619-543-4741 VCC: 760-631-5030 ext 122 SYHC: 619-428-4463
http://avrctrials.org/EIP.html
Mother, Child & Adolescent HIV Program UCSD - Meth Related Research HNRC- HIV Neurobehavioral Research Center
http://www.ucsdmcap.org/
Mary Caffery: 619-543-8080 x236
Website/Links
Contact Information Teresa Oyos: 619-543-5045 Crosby Vargas: 619-543-5040
http://www.hnrc.ucsd.edu/research/current.asp
149
SOCIAL AND MEDICAL SERVICES (continued)

Support Groups Website/Links Contact Information Information An organization with several programs for people living with HIV, including one for people who are newly diagnosed and have substance use issues. They offer case management and counseling to people who are enrolled in, or want to be enrolled in, alcohol and other drug treatment and recovery programs. A group for meth users with less than one year of sobriety. HIV positive individuals who have used meth are also encouraged to attend. A fellowship of men and women who share their experience, strength and hope with each other so they may solve their common problem and help others to recover from addiction to crystal meth. The only requirement for membership is a desire to stop using. The primary purpose is to lead a sober life and to carry the message of recovery to crystal meth addicts. Program offered incentives for providing meth free urine samples three times a week. The program ended September 2009 and is no longer enrolling new clients. Information Investigates reports of suspected child abuse and neglect and intervenes with families who do not meet the minimum community standards of health and safety as required by law. Coordinates law enforcement, medical services and child welfare workers to ensure that children found in homes and other environments where meth and other illegal substances are produced receive appropriate attention and care.
Jewish Family Service of San Diego Talking About Tina
http://www.jfssd.org/HIV
Joel Stegen: 858-637-3058 joels@jfssd.org
The LGBT Center So You Want to Get Off and Stay Off Meth
http://www.ourlgbtevents.org/event_view.php?eid=10 1&instance=2009-6-25
Johanna Malaret: 619-692-2077 jmalaret@bhs.thecentersd.org
Crystal Meth Anonymous 12 Step Program
www.crystalmeth.org
619-342-1656
Positive Reinforcement Opportunity Project (PROP) Child Welfare Services
www.fhcsd.org
Debbie Hamilton: 619-515-2588 debbieh@fhcsd.org
Website/Links http://www.sdcounty.ca.gov/hhsa/programs/cs/child_ welfare_services/index.html
Contact Information
Child Welfare
858-694-5191
Drug Endangered Children
http://www.nationaldec.org/
Patricia Devlin: 858-694-5271
150
DATA AND RESEARCH

UCSD The EDGE Project Website/Links http://psychiatry.ucsd.edu/faculty/tpatterson_CS_The Edge.html Contact/Information Jim Zians: 619-543-5086 jzians@ucsd.edu Information A behavior change and maintenance intervention and research project for meth using HIV positive men who have sex with men. A cognitive/behavioral research project at Owen Clinic. Primary prevention with positives focusing on high-risk sexual and drug using behaviors. The intervention included a meth-specific track. A psychiatric research study for sexually HIV negative heterosexual men and women who have used meth within the last two months. Information The purpose of this large-scale study was to replicate the Matrix outpatient treatment model and compare it to Treatment as Usual at eight national sites. In San Diego, treatment services were provided at Family Recovery Center in Oceanside, and the evaluation was conducted by SANDAG. The purpose of the Substance Abuse Monitoring (SAM) program is to identify drug use trends among the adult and juvenile offender populations in order to develop appropriate strategies for the prevention of drug abuse. The goal of this behavior change campaign and evaluation project is to encourage the target populations to utilize HIV counseling and testing services, seek primary care and/or to increase the use of education and prevention, risk reduction or harm reduction strategies. Information The Meth Strike Force develops an annual report card with eight indicators, tracks media stories and Hotline calls.
Supporting Positive Living and Sexual Health (SPLASH)
N/A Project ended in 2007.
No contact information available
Fast Lane SANDAG MTP: HEARTT Methamphetamine Treatment Project: Helping Every Addict Recover Through Treatment
N/A Website/Links
Jim Zians: 619-543-5086 jzians@ucsd.edu Contact Information
Project ended in 2003. http://sandiegohealth.org/sandag/publicationid_859_1 882.pdf
Cynthia Burke: 619-699-1910 cbu@sandag.org
Substance Abuse Monitoring (SAM)
http://www.sandag.org/index.asp?projectid=73&fusea ction=projects.detail
Cynthia Burke: 619-699-1910 cbu@sandag.org
High Risk Behavior Change Campaign Evaluation
http://www.sandag.org/index.asp?projectid=266&fuse action=projects.detail
SANDAG: 619-699-1900 Lisbeth Howard: 619- 699-6910 lho@sandag.org Contact Information 1-877-No2Meth www.no2meth.org Angela Goldberg: 760-749-8792 angelagoldberg@sbcglobal.net
Meth Strike Force Meth Strike Force Meth Report Card
Website/Links http://www.no2meth.org/docs/2005_2006_sdreportcar d.pdf
151
DATA AND RESEARCH (Continued)

HIV Substance Abuse and Prevention Treatment (HIV set aside) San Diego County HIV Risk Behavior and HIV Prevention Services Report Website/Links Contact Information Information Two survey efforts completed to assess the needs of individuals living with HIV/AIDS and the availability of HIV and STD prevention services: one with individuals themselves and one with providers who serve them. Building on efforts that began in 2005, information was gathered through surveys with service providers in 2008 and focus groups with HIV prevention service providers in 2009 to help the County be better equipped to address meth-related issues in relation to the risk of HIV transmission. This report provides a summary of these recent information gathering efforts, links common themes reported through the surveys and focus groups and provides recommendations based on the information gathered. In this study, 40 key informant interviews were conducted in addition to 393 community surveys. Both surveys included survey items intended to measure community readiness as well as awareness about substance abuse as a risk factor for HIV, attitudes regarding substance abuse as a risk factor for HIV and support for specific HIV prevention activities and policies. Contact Information Information The primary focus for methamphetamine prevention services is to reduce the number of children exposed to methamphetamine and other manufactured illegal drugs and their precursor chemicals.
Report available at: www.sdhivprevention.org
N/A
Meth and HIV in San Diego County: A Provider and Community Assessment
N/A
LGBT Community Readiness Assessment to Address Substance Use as a Risk Factor for HIV
N/A
Methamphetamine Strike Force / Methamphetamine Prevention Methamphetamine Strike Force/Methamphetamine Prevention Initiative (ADS)
Website/Links
www.no2meth.org
Angela Goldberg: 760-749-8792 angelagoldberg@sbcglobal.net
152
MEDIA
Social Marketing Website/Links Contact/Information Information A website developed in San Diego that provides factual information, without judgment or stigma, to the lesbian, gay, and bisexual men who use crystal meth or to those who know someone who uses. The purpose is to stimulate awareness, dialogue, knowledge and action, be it personal or otherwise, in dealing with meth use in our community. A website where the public can get information, report meth-related crime and obtain referrals for treatment. A website that seeks to prevent methamphetamine abuse, encourage discontinued use and motivate individuals to seek help through community outreach, public policy and public education. A guide to learn more about meth with messages on how users can protect themselves and those they care about. Information The Countywide Media Advocacy Project develops materials, tools and other data for ADS-funded providers to advance media advocacy and policy in San Diego.
Know Crystal
www.knowcrystal.org
David Contois: 619-990-6089
Crystal Mess
www.no2meth.org
General Number: 1-877-No-2-Meth info@no2meth.org 1-866-787-METH After hours and weekends call the National Alcohol and Drug Clearinghouse: 1-800-729-6686 Victoriano Diaz: 619-515-2589 victorianod@fhcsd.org Contact Information Susan Caldwell, MPI Chair Institute for Public Strategies: 619-456-9607 scaldwell@publicstrategies.org
Me Not Meth
www.menotmeth.org
Meth Free Life Media Advocacy ADS Countywide Media Advocacy
www.methfreelife.com Website/Links http://www.publicstrategies.org/east/pdf/SocialHostFa ctSheetPDF.pdf
153
EDUCATION
Education Website/Links Contact Information Information The County of San Diego contracts with Community Based Organizations to provide HIV education and prevention services. With the high correlation between meth use and HIV transmission, the HIV prevention providers are well trained in providing harm reduction counseling for active meth users, referrals to local substance abuse treatment programs, support while clients are waiting for admission into treatment programs and support to reduce harms associated with meth use and for continued abstinence from meth. Each program offers interventions along the continuum including outreach, groups, individual risk reduction counseling, large community events and behavior change campaigns. Please visit www.sdhivprevention.org to get a full description of services offered by the HIV education and prevention programs. To be added as they are conducted. Crystal Darkness reaches out in an unprecedented television event that uses the power of media, government, treatment professionals, churches and businesses in an innovative and targeted way. The Meth Strike Force Education Committee works on expanding school-based meth prevention and interventions. Presentations and support for neighborhood safety.
HIV Education and Prevention Programs (see Appendix M for brochure)
www.sdhivprevention.org
Lori Jones: 619-293-4755 lori.jones@sdcounty.ca.gov
Community Forums
NA
To be entered as they are conducted 775-853-8333 info@crystaldarkness.com
Meth Solutions Prevention Video
http://www.crystaldarkness.com/documentry.asp
MSF Education Committee
www.no2.meth.org
Jim Crittenden: (619) 718-4998 jimcritt@sdcoe.net Marlee Chapman: 858-974-2289 marlee.chapman@sdsheriff.org
Sheriff Crime Prevention
http://www.sdsheriff.net/co_crimeprevention.html
154
APPENDIX G GAP ANALYSIS AND SUMMARY FY 2008/2009
155
156
APPENDIX G GAP ANALYSIS AND SUMMARY FY 2008/2009 The methodology utilized to complete the gap analysis was as follows. Epidemiological data for HIV and AIDS incidence (2003-2007) and prevalence (all known cases) and testing (from County and County-funded testing sites) for San Diego County were entered into an Excel spreadsheet (see the first five columns of the gap analysis on pages 161-167). Education and prevention service delivery data for FY 2008/2009 from the Prevention Outcome Database (see page 31 for information on POD) was entered into the Excel spreadsheet (see the sixth column). For reference but not included in the analysis, data for education and prevention service delivery for FY 2007/2008 was entered into the Excel spreadsheet (see seventh column). Significant differences between POD data and incidence and prevalence data were determined at p<0.05 using Excel statistical formulae. Gaps in HIV education and prevention services were identified when there was a statistical difference (p<.05) in service delivery measured by data from the Prevention Outcomes Database (POD) compared to epidemiological data for HIV/AIDS incidence, prevalence and testing. POD data includes services for individual and group interventions and does not include outreach and public information/presentations. POD data were run by ZIP code of residence and all epidemiological data are for residence. The gaps noted below are based on the residence of the individuals receiving prevention services. Analysis done by ZIP code of service data is used by providers to assess if programs are serving behavioral risk groups to the degree that they exist in the epidemiology in the regions where they provide services. Three levels of priority for gaps were identified: High priority gaps were identified when statistical difference (p<.05) in service delivery measured by data from POD compared to epidemiological data existed for all five data sources including AIDS incidence and prevalence, HIV incidence and prevalence and HIV counseling and testing data. Medium priority gaps were identified when statistical difference (p<.05) in service delivery measured by data from POD compared to epidemiological data existed in three or more data sources including both AIDS incidence and prevalence. Low priority gaps were identified when statistical difference (p<.05) in service delivery measured by data from POD compared to epidemiological data existed in any other two or more data sources. Other gaps were reviewed but not prioritized to focus effort on higher priority gaps as identified above.
157
A summary of the high and medium priority gaps identified in the gap analysis are as follows: Countywide and in the Central and North Central regions, HIV prevention service high priority gaps were identified for males and a medium priority gap was identified in the East region. Only the North Coastal and South regions did not have a service gap for males. Countywide and in the Central and North Inland regions, high priority gaps were identified for MSM. In North Central, East and North Coastal regions, medium priority gaps were identified for MSM. Only in the South region was there no gap for MSM identified.
The following table contains the data from the Excel spreadsheet utilized to analyze services delivery gaps. The percentages in bold and underlined represent a statistical difference between the percentage of individuals receiving services compared to those documented in County data systems to be living with HIV and/or AIDS; those receiving services are under represented compared to those in County data systems. These are the percentages that establish the service delivery gaps indicating a group is underrepresented for services. Shaded percentages indicate where a group is over represented in the data for services. The following is an example of gaps for gender in San Diego County. POD service delivery data indicate 23 percent of HIV education and prevention services were delivered to women, 72 percent to men and 5 percent to transgender for FY 2008/2009 (see column six). All data sources indicate males are under represented for services: 72 percent received services in comparison to 89 percent of incident AIDS cases (column one), 90 percent of incident HIV cases (column two), 89 percent of those testing for HIV (column three), 91 percent of prevalent AIDS cases (column four) and 90 percent of prevalent HIV cases (column five). It is a contract requirement for all HIV education and prevention providers to serve those individuals at risk for HIV to the degree that there are people living with HIV/AIDS in the region(s) where services are being delivered. A gap analysis was completed for each region to guide planning and delivery of HIV education and prevention services. The highest priority gaps identified in the FY 2008/2009 that are currently being addressed by providers are additional services for men and specifically MSM. (See the Gap Analysis Summary FY 2008/2009 for countywide and region specific gaps; all of the data to substantiate service delivery gaps can be found in the San Diego County Gap Analysis Table on pages 161-167.)
158
GAP ANALYSIS SUMMARY FY 2008-2009

DEMOGRAPHICS
Gender: Males BRG: MSM Region: North Central Region: South Race/Gender: White males Race/Gender: Latinas Gender: Males BRG: MSM Race/Gender: White males Race/Gender: African American females Region: North Central Gender: Males BRG: MSM Gender: Males BRG: MSM BRG: MSM Gender: Male BRG: MSM Region: South Race/Gender: White males Race/Gender: African American females Race/Gender: API/other females
HIV PREVENTION SERVICE GAPS BY REGION

San Diego County
High priority gap based on all data sources. High priority gap based on all data sources. Low priority gap based on AIDS and HIV prevalence. Low priority gap based on AIDS incidence, HIV Incidence and testing data. Low priority gap based on AIDS and HIV prevalence and HIV incidence data. Low priority gap based on AIDS incidence and testing data.
Central Region
High priority gap based on all data sources. High priority gap based on all data sources. Low priority gap based on AIDS and HIV prevalence and HIV incidence data.
Low priority gap based on HIV prevalence and incidence data.
North Central Region

Low priority gap based on AIDS and HIV prevalence data. High priority gap based on all data sources. Medium priority gap based on AIDS and HIV prevalence and incidence data.
East Region
Medium priority gap based on AIDS prevalence and incidence and HIV prevalence data. Medium priority gap based on AIDS and HIV prevalence and incidence data.
North Coastal Region

Medium priority gap based on AIDS and HIV prevalence and incidence data.
North Inland Region

Low priority gap based on AIDS prevalence and incidence. High priority gap based on all data sources.
South Region
Low priority gap based on AIDS incidence, HIV Incidence and testing data. Low priority gap based on AIDS and HIV prevalence data.
Low priority gap based on AIDS and HIV prevalence data.
Low priority gap based on AIDS and HIV prevalence data.
159
160
San Diego County Gap Analysis: FY 2008/2009

Highlighted/bolded areas indicate a statistically significant difference compared to POD (p<.05). Bold indicates a greater percentage and over-represented compared to POD data. Shaded indicates a smaller percentage and under-represented compared to POD data.
AIDS1
2003 - 2007
HIV1
2003 - 2007
HCT1
2003 - 2007
AIDS2
Prevalence
HIV2
Prevalence
POD 4,7,8
2008-2009
ELI3,4,5
2007-2008
Comments
Females Males Transgender Unknown Gender Males by Race/Ethnicity White Hispanic African American API/Other
% 11% 89% -
# 214 1732 0
% 10% 90% -
# 131 1217 0
% 9% 89% 1% -
# 83 744 9 0
% 9% 91% -
# 620 5937 0
% 10% 90% -
# 356 3151 0
% 23% 72% 5% <1
# 373 1175 86 4
% 28% 70% 3% 0%
# 486 1223 40 7
47% 36% 14% 4%
811 619 233 69 1732
54% 31% 12% 4%
657 373 140 47 1217
40% 43% 9% 8%
302 323 63 61 749
55% 29% 13% 3%
3244 1700 797 196 5937
62% 25% 10% 3%
1947 791 312 101 3151
47% 37% 14% 10%
551 440 164 113 1175
42% 40% 12% 6%
515 486 142 80 1223
Females by Race/Ethnicity White Hispanic African American API/Other
23% 51% 22% 5%
49 108 47 10 214 1017 205 146 141 85 352 0 1313 175 176 259 23 1946
32% 38% 28% 2%
42 49 37 3 131 789 143 87 93 47 189 0 995 82 77 124 70 1348
21% 60% 17% 2%
18 52 15 2 87 405 73 33 39 21 225 40 509 68 22 34 114 89 836
42% 35% 18% 5%
261 215 114 30 620 3684 741 425 499 281 927 0 4686 567 625 572 107 6557
33% 36% 27% 4%
119 129 94 14 356 2112 401 218 227 125 424 0 2628 193 239 324 123 3507
41% 36% 22% 11%
153 135 83 42 373 992 144 114 88 103 197 0 669 74 213 160 397 125 1638
42% 34% 17% 7%
207 164 81 34 486 960 184 141 165 49 179 78 461 225 160 357 274 1756
Denominator for 07/08 ELI mode is 1477
Central North Central East North Coastal North Inland South Region Unknown MSM (Male Only) Bisexual (M/F) IDU (Hetero M/F) MSM/IDU (Male only) Heterosexual Other/Unknown Total
52% 11% 8% 7% 4% 18% 68% 9% 9% 13% 1% 100%
59% 11% 6% 7% 3% 14% 74% 6% 6% 9% 5% 100%
48% 9% 4% 5% 3% 27% 5% 61% 8% 3% 4% 14% 11% 100%
56% 11% 7% 8% 4% 14% 71% 9% 10% 9% 1% 100%
60% 11% 6% 6% 4% 12% 75% 5% 7% 9% 4% 100%
61% 9% 7% 5% 6% 12%
55% 10% 8% 9% 3% 10% 4% 31% 15% 11% 24% 19% 100%
41% 5 13% 10% 24% 8% 100%
161
Central Region
AIDS1
2003 - 2007
HIV1
2003 - 2007
HCT1
2003 - 2007
AIDS2
Prevalence
HIV2
Prevalence
POD 4,7,8
2008-2009
ELI3,4,5
2007-2008
Comments
% 9% 91% -
# 93 924 0
% 7% 93% -
# 58 731 0
% 5% 93% 2% -
# 20 378 7 0
% 7% 93% -
# 258 3426 0
% 7% 93% -
# 140 1972 0
% 23% 70% 6% <1%
# 229 698 63 2
% 26% 71% 3% <1%
# 249 684 25 2
54% 27% 15% 4%
498 252 139 35 924
59% 26% 11% 4%
432 189 81 29 731
53% 27% 10% 10%
202 103 37 40 382
58% 25% 14% 3%
1975 870 471 110 3426
66% 20% 10% 4%
1308 402 199 63 1972
48% 35% 14% 11%
335 246 99 76 698
44% 37% 14% 5%
300 255 92 37 684
24% 37% 34% 5%
22 34 32 5 93 739 68 105 96 9 1017
31% 22% 45% 2%
18 13 26 1 58 606 41 49 58 35 789
43% 13% 35% 9%
10 3 8 2 23 280 27 9 25 33 31 405
41% 29% 27% 4%
106 74 69 9 258 2776 268 405 204 31 3684
24% 31% 44% 1%
34 44 61 1 140 1685 84 153 133 57 2112
39% 38% 23% 14%
90 87 53 33 229 388 50 104 106 248 93 992
40% 33% 19% 8%
100 81 47 21 249 269 89 99 150 179 1182

MSM (Male Only) Bisexual (M/F) IDU (Hetero M/F) MSM/IDU (Male only) Heterosexual Other/Unknown Total
73% 7% 10% 9% 1% 100%
77% 5% 6% 7% 5% 100%
69% 7% 2% 6% 8% 8% 100%
75% 7% 11% 6% 1% 100%
80% 4% 7% 6% 3% 100%
39% 5% 10% 11% 25% 10% 100%
34% 11% 13% 19% 23% 100%
162
North Central Region

AIDS1
2003 - 2007
HIV1
2003 - 2007
HCT1
2003 - 2007
AIDS2
Prevalence
HIV2
Prevalence
ELI 4,7,8
2008-2009
ELI3,4,5
2007-2008
Comments
% 5% 95% -
# 11 189 0
% 6% 94% -
# 9 134 0
% 5% 95% -
# 4 69 0 0
% 10% 90% -
# 75 666 0
% 10% 90% -
# 39 362 0
% 35% 63% 2% 0%
# 51 90 3 0
% 41% 58% <1% 1%
# 75 106 1 2
64% 16% 14% 6%
120 31 27 11 189
63% 21% 12% 4%
84 28 16 6 134
49% 28% 13% 10%
34 19 9 7 69
61% 22% 13% 4%
403 149 85 29 666
72% 16% 9% 3%
259 57 33 13 362
62% 18% 18% 14%
56 16 16 13 90
53% 24% 15% 8%
56 25 16 9 106
36% 36% 27% 0%
4 4 3 0 11 147 12 13 26 2 200
56% 22% 22% 0%
5 2 2 0 9 118 5 1 11 8 143
75% 25% 0% 0%
3 1 0 0 4 43 8 1 2 9 10 73
56% 25% 16% 3%
42 19 12 2 75 551 50 48 73 19 741
56% 15% 21% 8%
22 6 8 3 39 323 13 9 40 16 184
33% 22% 41% 8%
17 11 21 4 51 60 9 23 9 30 13 144
47% 16% 31% 6%
35 12 23 5 75 44 28 9 56 30 256
73% 6% 7% 13% 1% 100%
82% 4% 1% 8% 5% 100%
59% 11% 1% 3% 12% 14% 100%
74% 7% 7% 10% 2% 100%
81% 3% 2% 10% 4% 100%
42% 6% 16% 6% 21% 9% 100%
26% 17% 5% 34% 18% 100%
163
East Region
AIDS1
2003 - 2007
HIV1
2003 - 2007
HCT1
2003 - 2007
AIDS2
Prevalence
HIV2
Prevalence
POD 4,7,8
2008-2009
ELI3,4,5
2007-2008
Comments
% 13% 87% -
# 19 127 0
% 20% 80% -
# 17 70 0
% 24% 76% -
# 8 25 0 0
% 13% 87% -
# 54 371 0
% 23% 77% -
# 51 167 0
% 25% 71% 4% -
# 29 81 4 0
% 29% 70% <1% <1%
# 41 98 1 1
42% 32% 21% 6%
53 41 26 7 127
63% 21% 13% 3%
44 15 9 2 70
52% 20% 20% 8%
13 5 5 2 25
51% 28% 18% 3%
190 104 65 12 371
66% 21% 9% 4%
110 35 15 7 167
59% 30% 17% 10%
48 24 14 8 81
44% 33% 13% 10%
43 32 13 10 98
53% 32% 11% 5%
10 6 2 1 19 85 27 15 19 0 146
47% 35% 18% 0%
8 6 3 0 17 53 6 7 15 6 87
13% 50% 37% 0%
1 4 3 0 8 15 1 3 1 6 7 33
59% 19% 13% 9%
32 10 7 5 54 279 57 40 43 6 425
51% 25% 24% 0%
26 13 12 0 51 132 20 16 39 11 218
72% 17% 14% 10%
21 5 4 3 29 44 7 17 10 29 7 114
66% 22% 7% 5%
27 9 3 2 41 23 21 10 47 26 180
58% 18% 10% 13% 100%
61% 7% 8% 17% 7% 100%
46% 3% 9% 3% 18% 21% 100%
66% 14% 9% 10% 1% 100%
61% 9% 7% 18% 5% 100%
39% 6% 15% 9% 25% 6% 100%
18% 17% 8% 37% 20% 100%
164
North Coastal Region

AIDS1
2003 - 2007
HIV1
2003 - 2007
HCT1
2003 - 2007
AIDS2
Prevalence
HIV2
Prevalence
POD 4,7,8
2008-2009
ELI3,4,5
2007-2008
Comments
% 16% 84% -
# 23 125 0
% 15% 85% -
# 14 79 0
% 18% 79% 3 -
# 7 31 1 0
% 14% 86% -
# 72 427 0
% 19% 81% -
# 43 184 0
% 22% 69% 8% 1%
# 19 61 7 1
% 20% 77% 2% <1%
# 33 127 4 1
46% 38% 10% 6%
58 47 12 8 125
47% 37% 11% 5%
37 29 9 4 79
55% 32% 3% 10%
17 10 1 3 31
55% 30% 12% 3%
233 127 52 15 427
62% 24% 10% 4%
114 45 19 6 184
59% 38% 3% 5%
36 23 2 3 61
55% 28% 9% 9%
70 35 11 11 127
4% 57% 30% 9%
1 13 7 2 23 82 19 12 32 3 148
29% 42% 29% 0%
4 6 4 0 14 65 2 4 16 6 93
13% 62% 25% 0%
1 5 2 0 8 15 4 5 3 6 6 39
33% 40% 21% 6%
24 29 15 4 72 311 59 39 74 16 499
35% 37% 19% 9%
15 16 8 4 43 145 11 15 44 12 227
53% 32% 11% 5%
10 6 2 1 19 26 6 24 10 17 5 88
70% 9% 12% 9%
23 3 4 3 33 37 52 24 33 10 193
55% 13% 8% 22% 2% 100%
70% 2% 4% 17% 7% 100%
38% 10% 13% 8% 15% 15% 100%
62% 12% 8% 15% 3% 100%
64% 5% 7% 19% 5% 100%
30% 7% 27% 11% 19% 6% 100%
24% 33% 15% 21% 6% 100%
165
North Inland Region

AIDS1
2003 - 2007
HIV1
2003 - 2007
HCT1
2003 - 2007
AIDS2
Prevalence
HIV2
Prevalence
POD 4,7,8
2008-2009
ELI3,4,5
2007-2008
Comments
% 13% 87% -
# 11 72 0
% 15% 85% -
# 7 40 0
% 10% 90% -
# 2 19 0
% 14% 86% -
# 38 243 0
% 19% 81% -
# 24 101 0
% 24% 70% 6% -
# 25 72 6 0
% 35% 59% 6% -
# 17 29 3 0
50% 43% 4% 3%
36 31 3 2 72
55% 38% 1% 5%
22 15 1 2 40
53% 37% 5% 5%
10 7 1 1 19
58% 29% 9% 4%
141 70 22 10 243
63% 31% 3% 3%
64 31 3 3 101
42% 29% 21% 13%
30 21 15 9 72
59% 34% 0% 7%
17 10 0 2 29
27% 55% 9% 9%
3 6 1 1 11 54 7 4 14 4 83
29% 57% 0% 14%
2 4 0 1 7 27 4 6 6 4 47
100% 0% 0% 0%
2 0 0 0 2 16 0 0 0 2 3 21
32% 42% 11% 16%
12 16 4 6 38 183 32 18 35 13 281
46% 46% 4% 4%
11 11 1 1 24 78 9 11 20 7 125
56% 28% 12% 4%
14 7 3 1 25 32 1 19 17 33 1 103
41% 41% 12% 6%
7 7 2 1 17 16 7 3 12 7 63
65% 8% 5% 17% 5% 100%
57% 9% 13% 13% 8% 100%
76% 10% 14% 100%
65% 11% 6% 13% 5% 100%
62% 7% 9% 16% 6% 100%
31% 1% 18% 17% 32% 1% 100%
36% 16% 7% 27% 16% 100%
166
South Region
AIDS1
2003 - 2007
HIV1
2003 - 2007
HCT1
2003 - 2007
AIDS2
Prevalence
HIV2
Prevalence
POD 4,7,8
2008-2009
ELI3,4,5
2007-2008
Comments
% 16% 84% -
# 57 295 0
% 14% 86% -
# 26 163 0
% 17% 83% -
# 38 187 0
% 13% 87% -
# 123 804 0
% 14% 86% -
# 59 365 0
% 10% 88% 2% <1%
# 20 173 3 1
% 28% 69% 3% <1%
# 50 124 4 1
16% 74% 9% 2%
46 217 26 6 295
23% 60% 15% 2%
38 97 24 4 163
8% 87% 3% 2%
16 163 5 3 187
38% 47% 13% 2%
302 380 102 20 804
25% 61% 12% 2%
92 221 43 9 365
27% 64% 10% 2%
43 110 18 4 173
5% 88% 2% 5%
6 109 2 7 124
16% 79% 4% 2%
9 45 2 1 57 206 42 27 72 5 352
19% 69% 8% 4%
5 18 2 1 26 126 24 10 18 11 189
0% 95% 5% 0%
0 36 2 0 38 116 25 3 2 53 26 225
37% 55% 6% 3%
45 67 7 4 123 586 101 75 143 22 927
19% 66% 7% 8%
11 39 4 5 59 265 56 35 48 20 424
5% 95% 0% 0%
1 19 0 0 20 119 1 26 8 40 3 197
16% 82% 2% 0%
8 41 1 0 50 50 26 5 38 14 224
58% 12% 8% 21% 1% 100%
66% 13% 5% 10% 6% 100%
52% 11% 1% 1% 24% 12% 100%
63% 11% 8% 15% 3% 100%
63% 13% 8% 11% 5% 100%
60% 1% 13% 4% 20% 2% 100%
38% 20% 4% 29% 11% 100%
Note 1 Data Source: Region Briefs for AIDS, HIV and HCT 2003-2007, compiled by Community Epidemiology Branch (HCT data includes only HIV positive tests) Note 2 Data Source: Living AIDS and HIV cases diagnosed through June 30th, 2008, Community Epidemiology Branch Note 3 Data Source: Evaluating Local Interventions (ELI) data - Individual Level (ILI) and Group Level (GLI) Interventions Note 4 Data contains both HIV positive and negative clients Note 5 Mode of transmission was captured for a sub-sample of clients served; the total is less than indicated Note 6 HCT does not allow testing of anyone under the age of 12. This group (0-12) only includes age 12 for HCT data Note 7 Data source: Prevention Outcome Database (POD) Note 8 Clients could chose more than one race/ethnicity, so totals and percentages sub to great than the total unduplicated number and greater than 100% Percentages may not total 100 due to rounding. County of San Diego, Community Epidemiology, 5/20/09
167
168
APPENDIX H PARTNER SERVICES SUMMARY
169
170
APPENDIX H PARTNER SERVICES SUMMARY

Partner Services assists people living with HIV in notifying sex and/or needle sharing partners of a possible exposure to HIV. Partner Services are voluntary, confidential and free. Notification of possible HIV exposure to partners is provided by trained County of San Diego Public Health staff. Trained provider staff offer assistance and elicit information to notify partners of possible exposure. Training is available upon request through the HIV, STD and Hepatitis Branch of Public Health Services.
Partner Services (PS) Disclosure Assistance Options

3. Anonymous, Third Party Notification
1. Self Disclosure
If the HIV positive individual chooses to self-disclose and tell their partners themselves, providers work with the client on techniques to self-disclose such as discussing concerns, offering to role play and providing referrals for testing. Provider: Completes PS information on appropriate form (CIF or HERR) and enters completed form into LEO.
2. Dual Disclosure
If the HIV-positive individual chooses a dual-disclosure and tells their partners with a provider present, client is referred to a trained staff person who can assist with a dualdisclosure. Clients who choose this option must tell their partners their status, and the provider staff person is available to answer questions or make referrals and even to offer HIV testing as appropriate. Provider: Completes appropriate form (CIF or HERR) and a Partner Information Form (PIF) for each partner and enters all forms into LEO.
If the HIV-positive individual chooses third party notification, the clients personal information will not be shared with the partner being notified. Notification is only done by trained Public Health staff. When notified, partners are offered testing and referrals for care and treatment. Provider: Completes the appropriate form (CIF or HERR) and a Partner Information Form (PIF) for each partner for which contact information has been elicited by staff trained in partner elicitation and enter all forms into LEO. If no trained staff is available, call (619) 692-8501 for assistance with eliciting partner information. Provider: Notifies HSHB Field Services that an anonymous third party notification is requested by calling (619) 692-8501. Provider: Fax CIF or HERR form, PIF and proof of positive test result to HSHB Field Services confidential fax at (619) 296-1705. Hand deliver or mail in double envelope original PIF to HSHB.
Contact us with any questions HIV, STD and Hepatitis Branch HSHB Field Services: (619) 692-8501 3851 Rosecrans Street, MC-P505 San Diego, CA 92110 Attn: Field Services/PS Confidential Fax: (619) 296-1705
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172
APPENDIX I 2010 NEEDS ASSESSMENT SUMMARY
173
174
APPENDIX I 2010 NEEDS ASSESSMENT SUMMARY 2010 HIV/AIDS Needs Assessment Report: Survey of People Living with HIV/AIDS Total Survey Sample
April 2010 For more information, contact Dan OShea (phone: 619-293-4710 / e-mail: dan.oshea@sdcounty.ca.gov) or Shannon Hansen (phone: 619-293-4719 / e-mail: shannon.hansen@sdcounty.ca.gov) 7,700 paper questionnaires distributed 1,072 survey responses o includes 147 surveys completed online Percentage Comparison of 2010 Survey Response Demographics by Region of Residence, Gender and Ethnicity to AIDS Surveillance Information % 2010 survey respondents % Recent AIDS Cases, SD County 1/08 - 12/09 51% 7% 13% 10% 19% N/A 89% 11% N/A 14% 3% 43% 38% 2% N/A % Living AIDS Cases, SD County as of 12/09 59% 8% 12% 7% 14% N/A 90% 10% N/A 13% 3% 52% 31% 1% N/A
Region
Region: Central San Diego Southeast San Diego North County East County South Bay Unidentified zip code Gender: Male Female Transgender Ethnicity: African American (Black) Asian/Pacific Islander Caucasian (White) Latino (Hispanic) Native American Other
47% 11% 13% 5% 10% 14% 81% 14% 2% 17% 3% 46% 34% 3% 2%
175
2010 Survey of People Living with HIV/AIDS (N=1,072) San Diego County, April 2010 1. Demographic Report Region Central San Diego............................................. 501 North County .................................................... 137 South Bay ......................................................... 110 Southeast San Diego......................................... 122 East County ........................................................ 55 No response or homeless.............................. 147 (47%) (13%) (10%) (11%) (5%) (14%) Age 0 to 5 years ...............................................................2 6 to 12 years .............................................................2 13 to 19 years ...........................................................3 20 to 24 years ........................................................38 25 to 29 years ........................................................56 30 to 39 years ...................................................... 215 40 to 49 years ...................................................... 409 50 to 59 years ...................................................... 239 60 to 69 years ........................................................76 70 to 79 years ........................................................10 80 to 89 years ...........................................................1 No response: ...........................................................21 HIV Health Status HIV positive, without symptoms.......................... 448 (42%) HIV positive, with symptoms ............................... 195 (18%) AIDS diagnosed.................................................... 429 (40%) (<1%) (<1%) (<1%) (4%) (5%) (20%) (38%) (22%) (7%) (1%) (<1%) (2%)
Gender Male.................................................................. 866 (81%) Female .............................................................. 150 (14%) Transgender ........................................................ 21 (2%) No response .........................................................35 (3%) Race/Ethnicity Adds up to more than 100% because some checked more than one African American or African (Black)............... 180 (17%) Asian or Pacific Islander..................................... 28 (3%) Caucasian (White) ............................................ 493 (46%) Latino (Hispanic).............................................. 366 (34%) Native American (American Indian) .................. 33 (3%) Other racial/ethnic group ................................... 17 (2%) No response ....................................................... 16 (2%) Substance Use/Abuse In the last 12 months, regularly: Drank alcohol ................................................... 282 Used marijuana recreationally ......................... 132 Used meth (crystal, methamphetamine) ........... 113 Used other illegal drugs...................................... 61 Used prescription drugs recreationally............... 26 (26%) (12%) (11%) (6%) (2%)
Sexual Orientation Gay or lesbian (homosexual)................................ 630 (59%) Heterosexual (straight) ......................................... 287 (27%) Bisexual ..................................................................87 (8%) Other ......................................................................12 (1%) No response ...........................................................56 (5%)
Injection Drug Use Shot up (injected) drugs (IV drugs) in last 12 months ................................................59 Shot up drugs (IV drugs) in past, but have not shot up in past 12 months ...................................82 Shot up drugs in past, but now in recovery...........103 Never shot up IV drugs.........................................549
(6%) (8%) (10%) (51%)
Think may have drug or alcohol problem............... 79 (7%) Think have had alcohol problem, but no longer use alcohol.......................................... 97 (9%) Think have had drug problem, but no longer use drugs........................................... 181 (17%) In recovery............................................................ 207 (19%)
176
Current/Previous Incarceration Currently incarcerated (in jail or prison) .............. 19 (2%) Ex-inmate (have done time in any jail or prison) ....................................................... 138 (13%)
Language Preference English.................................................................. 823 Spanish ................................................................. 233 Tagalog.....................................................................1 American Sign Language .........................................2 Other.........................................................................5 (77%) (22%) (<1%) (<1%) (<1%)
Other Diseases History of chronic mental illness....................... 220 (21%) Now .................................................................. 168 (16%) Past .................................................................... 105 (10%) History of hemophilia/other bleeding disorder.... 15 (1%) Now ....................................................................... 7 (1%) Past ........................................................................ 8 (1%) History of hepatitis B......................................... 192 (18%) Now ..................................................................... 48 (5%) Past .................................................................... 152 (14%) History of hepatitis C......................................... 166 (16%) Now ................................................................... 100 (9%) Past ...................................................................... 80 (8%)
Sexually Transmitted Diseases in past 12 months: Chlamydia .......................................................... 38 (4%) Gonorrhea........................................................... 44 (4%) Syphilis............................................................... 81 (8%) Herpes................................................................. 88 (8%) Genital Warts...................................................... 82 (8%) Other STDs........................................................... 6 (1%) No STDs ........................................................... 369 (34%) Not tested for STDs in past 6 months................. 43 (4%) Other Permanent Disabilities (besides HIV/AIDS): Blind/visually impaired ..........................................45 (4%) Deaf/hard of hearing (use sign language) ...............13 (1%) Hard of hearing (do not use sign language) ...........51 (5%) Person with developmental disability .....................43 (4%) Physically disabled ............................................... 169 (16%) Other.......................................................................48 (4%)
History of MRSA (Methicillin-Resistant Staphylococcus Aureus; a staph infection) ......................... 99 (9%) If you answered yes to any of the above disabilities, did you Now ...................................................................... 19 (2%) Past ....................................................................... 82 (8%) become disabled (n=276) Pre-HIV .................................................... 70 (25%) Post-HIV..................................................128 (46%) History of tuberculosis ......................................... 98 (9%) As a result of HIV....................................125 (45%) Now ......................................................................... 7 (1%) Past ........................................................................ 91 (9%) Other Demographics Currently homeless ............................................. 117 (11%) Homebound (too sick to leave my home very often) ....................................................... 91 (9%) Too sick to prepare own meals ............................. 78 (7%)
How much is your average personal monthly income, including benefits payments? $0........................................................................134 (13%) $1 to $600.............................................................68 (6%) $601 to $800.........................................................90 (8%) $801 to $1,000 ....................................................244 (23%) $1,001 to $1,200 ...................................................86 (8%) $1,201 to $2,000 .................................................158 (15%) Above $2,000 .....................................................150 (14%) No response ........................................................ 142 (13%) Nation of Origin (n=127) Mexico....................................................................94 (74%) Ethiopia ....................................................................4 (3%) Guatemala.................................................................2 (2%) Asia, Brazil, Canada, Columbia, Cuba, England, Ghana, Middle East, Somalia (one response each) .............1 (1%) Not specified ..........................................................14 (11%)
Other Demographics Active duty military..............................................5 (1%) Veteran or retired military ................................186 (17%) Sex industry worker/prostitute............................30 (3%) Farm worker .........................................................6 (1%) Migrant worker...................................................26 (2%) Recent immigrant (last 2 years)..........................22 (2%) Recent immigrant (last 2-10 years)...................105 (10%)
177
2010 Survey of People Living with HIV/AIDS (N=1,072 unless specified) San Diego County, April 2010 2. HIV Medical Care: Access and Barriers Medical Care History Have been in medical care for HIV at any time, either now or in the past: Yes ............................................................... 977 (91%) No .................................................................. 76 (7%) No response ................................................... 19 (2%) Reason for NOT Getting HIV Medical Care for a Year or More (this past year OR some other time) (n=230 respondents to this question) Felt healthy...............................................................106 Using drugs or alcohol ...............................................68 Not ready to deal with having HIV ............................66 Not enough money or insurance.................................62 Side effects of medications .......................................51 Afraid people will find out I am HIV+.......................45 Homeless....................................................................45 Need someone to talk to who understands HIV .........33 Didnt know where to find the service .......................33 Didnt trust doctors or clinics.....................................32 My mental health problems........................................30 Didnt think Im eligible for services .........................29 Didnt think medical care will help me ......................28 Transportation or service location barrier ..................26 My physical disability ................................................18 Undocumented immigrant............................................8 My children, family or childcare needs........................8 Other ..........................................................................38 (46%) (30%) (29%) (27%) (22%) (20%) (20%) (14%) (14%) (14%) (13%) (13%) (12%) (11%) (8%) (3%) (3%) (17%) Out of Care Ever gone for more than a year without getting medical care for HIV ......................... 247 (23%) Currently out of care (no viral load, t-cell or HIV prescription in past 12 months)................ 30
(3%)
If you have gotten HIV medical care at some time, what made you decide to get it? (n=970 respondents to this question) Started care right after I tested positive............. 576 Got sick or started having symptoms of HIV.... 370 Got help from a case manager or peer advocate........................................................ 368 Accepted my test results.................................... 339 Got counseling or support ................................. 339 Got the information I needed ............................ 339 Was afraid of getting sick.................................. 226 My life became more stable .............................. 198 Got help with housing ....................................... 177 Got help for my alcohol or drug problem.......... 141 Other.................................................................... 60 How Medical Bills Are Paid (n=1,034 respondents to this question) ADAP.................................................................487 Ryan White Treatment Modernization Act ........457 Medi-Cal ............................................................359 Medicare.............................................................246 Private health insurance/HMO (individual or group) ...........................................................171 VA, Tri-Care or other military ...........................133 Not able to pay medical bills............................... 71 Private pay by self or family ............................... 52 County Medical Services .................................... 26 Do not have medical bills.................................... 22 Indian Health Service ............................................ 6 California Childrens Services .............................. 2 GHPP .................................................................... 0 (47%) (44%) (35%) (24%) (17%) (13%) (7%) (5%) (3%) (2%) (1%) (<1%) (0%) (59%) (38%) (38%) (35%) (35%) (35%) (23%) (20%) (18%) (15%) (6%)
178
2010 Survey of People Living with HIV/AIDS (N=1,072) San Diego County, April 2010 3. Services Used and Needed Service Category Used this service in the last year 535 (50%) 507 (47%) 425 (40%) 346 (32%) 279 (26%) 219 (20%) 211 (20%) 198 (19%) 191 (18%) 189 (18%) 181 (17%) 148 (14%) 138 (13%) 126 (12%) 106 (10%) 94 (9%) 65 (6%) 53 (5%) 36 (3%) 20 (2%) Need this service but cant get it 53 (5%) 28 (3%) 78 (7%) 248 (23%) 75 (7%) 120 (11%) 194 (18%) 59 (6%) 74 (7%) 48 (5%) 53 (5%) 108 (10%) 165 (15%) 86 (8%) 45 (4%) 89 (8%) 139 (13%) 48 (5%) 28 (3%) 30 (3%)
J. HIV/AIDS medications / medicines (as prescribed by a doctor) Q. Primary HIV medical care (doctor, clinic, nurse practitioner, etc.) B. Case management (ongoing help to get services or benefits, not just one-time) F. Dental care E. Counseling/therapy (individual or group by a professional) O. Medical specialist other than HIV specialist (hep C/liver, eye, ear, etc.) T. Transportation (bus pass, van service) D. Coordinated services center (drop in at one place for many services) M. Information and referral to services and how to get them (in writing, by phone or Internet, through a peer advocate) R. Psychiatric medication (for bi-polar, clinical depression, etc.) P. Peer advocacy or client advocacy (referral, advice to get services) N. Legal services L. Housing/shelter: permanent or ongoing help to pay rent I. Food: home-delivered meals A. Alcohol/drug recovery services/treatment G. Emergency housing/shelter: one-time or short-term emergency hotel stay H. Emergency utility payment (water, gas, electricity, phone) K. Home health care (nurse, attendant, hospice, physical therapy) S. Representative payee (someone who manages my money) C. Childcare (day care or babysitting)
NOTE: The 2008 survey included 19 service categories, while the 2010 survey includes 20 *In 2006, 17% (165 respondents) also identified Peer Advocacy as a service used in the past 12 months
179
2010 Survey of People Living with HIV/AIDS (N=845) San Diego County, April 2010 TOP 5 PRIORITY SERVICES Of all the services (A to S) listed, which 5 services are most important to you? Service Category 2010 Survey Results N= 845 Rank # Number (%) ranking among top 5 1 536 (63%) 2 453 (54%) 3 443 (52%) 4 364 (43%) 5 5 7 8 9 9 11 11 13 14 14 16 17 18 19 20 283 (33%) 283 (33%) 214 (25%) 202 (24%) 124 (15%) 124 (15%) 112 (13%) 112 (13%) 106 (13%) 100 (12%) 100 (12%) 94 (11%) 78 (9%) 41 (5%) 17 (2%) 14 (2%) 2008 Survey Results N= 730 Rank # Number (%) ranking among top 5 1 437 (60%) 2 432 (59%) 4 307 (42%) 3 359 (49%) 5 6 7 8 9 11 13 12 10 15 16 14 19 18 17 274 (38%) 240 (33%) 187 (26%) 178 (24%) 130 (18%) 125 (17%) 96 (13%) 119 (16%) 130 (18%) 87 (12%) 76 (11%) 95 (13%) 22 (3%) 23 (3%) 26 (4%)
J. HIV/AIDS medications / medicines (as prescribed by a doctor) Q. Primary HIV medical care (doctor, clinic, nurse practitioner, etc.) F. Dental care B. Case management (ongoing help to get services or benefits, not just one-time) L. Housing/shelter: permanent or ongoing help to pay rent T. Transportation (bus pass, van service) O. Medical specialist other than HIV specialist (hep C/liver, eye, ear, etc.) E. Counseling/therapy (individual or group by a professional) I. Food: home-delivered meals N. Legal services G. Emergency housing/shelter: one-time or short-term emergency hotel stay R. Psychiatric medication (for bi-polar, clinical depression, etc.) A. Alcohol/drug recovery services/treatment D. Coordinated services center (drop in at one place for many services) H. Emergency utility payment (water, gas, electricity, phone) M. Information and referral to services and how to get them (in writing, by phone or Internet, through a peer advocate) P. Peer advocacy or client advocacy (referral, advice to get services) K. Home health care (nurse, attendant, hospice, physical therapy) S. Representative payee (someone who manages my money) C. Childcare (day care or babysitting)
NOTE: The 2008 survey included 19 service categories, while the 2010 survey includes 20 * In 2006, Peer Advocacy was ranked #15, with 10% (100) of respondents identifying it as a top 5 priority
180
2010 Survey of People Living with HIV/AIDS (N=1,072) San Diego County, April 2010 Comparison Between 2010 and 2008 Surveys: SERVICES NEEDED, BUT CANT GET Service Category 2010 Survey Results N=1072 Rank # Number (%) who need but cant get 1 248 (23%) 2 194 (18%) 3 165 (15%) 4 120 (11%) 5 6 7 7 9 10 11 12 13 13 15 15 17 18 19 19 108 (10%) 89 (8%) 86 (8%) 86 (8%) 78 (7%) 75 (7%) 74 (7%) 59 (6%) 53 (5%) 53 (5%) 48 (5%) 48 (5%) 45 (4%) 30 (3%) 28 (3%) 28 (3%) 2008 Survey Results N=840 Rank # Number (%) who need but cant get 2 116 (14%) 5 83 (10%) 1 122 (15%) 8 57 (7%) 3 6 4 9 11 12 7 10 16 13 15 14 18 19 17 87 (10%) 74 (9%) 86 (10%) 55 (7%) 48 (6%) 44 (5%) 59 (7%) 49 (6%) 28 (3%) 38 (5%) 32 (4%) 33 (4%) 28 (3%) 24 (3%) 27 (3%)
F. Dental care T. Transportation (bus pass, van service) L. Housing/shelter: permanent or ongoing help to pay rent O. Medical specialist other than HIV specialist (hep C/liver, eye, ear, etc.) N. Legal services G. Emergency housing/shelter: one-time or short-term emergency hotel stay H. Emergency utility payment (water, gas, electricity, phone) I. Food: home-delivered meals B. Case management (ongoing help to get services or benefits, not just one-time) E. Counseling/therapy (individual or group by a professional) M. Information and referral to services and how to get them (in writing, by phone or Internet, through a peer advocate) D. Coordinated services center (drop in at one place for many services) J. HIV/AIDS medications / medicines (as prescribed by a doctor) P. Peer advocacy or client advocacy (referral, advice to get services) K. Home health care (nurse, attendant, hospice, physical therapy) R. Psychiatric medication (for bi-polar, clinical depression, etc.) A. Alcohol/drug recovery services/treatment C. Childcare (day care or babysitting) Q. Primary HIV medical care (doctor, clinic, nurse practitioner, etc.) S. Representative payee (someone who manages my money)
NOTE: The 2008 survey included 19 service categories, while the 2010 survey includes 20
181
2010 Survey of People Living with HIV/AIDS (N=1,072 unless specified) San Diego County, April 2010 4. Housing Needs How much do you spend each month on your rent or mortgage (your share only)? $0 .............................................................. 138 (13%) $1 to $200 ................................................... 53 (5%) $201 to $300 ............................................. 134 (13%) $301 to $400 ............................................... 79 (7%) $401 to $500 ............................................. 104 (10%) $501 to $800 ............................................. 206 (19%) Above $800 .............................................. 215 (20%) No response .............................................. 143 (13%) Where are you living today? (n=992) Own or rent a house, apartment, room or mobile home ................................. 691 Stay for free (crashing) with friends or relatives....................... 108 In a licensed facility (home, hospice, nursing, RCFCI, etc.) ..................... 11 In a drug or alcohol recovery home or treatment center ............................. 33 In a transitional housing program ............. 57 In a hotel, motel or SRO........................... 13 Homeless .................................................. 43 In an emergency shelter ..............................2 Other......................................................... 34 Percentage of income spent on rent 0% ..............................................................47 (4%) 1% to 10%..................................................10 (<1%) 11% to 25%..............................................100 (9%) 26% to 50%..............................................329 (31%) 51% to 75%..............................................151 (14%) 76% to 85%................................................33 (3%) 86% to 100%..............................................30 (3%) More than 100%.........................................27 (3%) No response on income and/or rent .........345 (32%) Did you have to move in the last 2 years because you could no longer pay your rent? (n=1004)
(70%) (11%)
Yes .................................................................. 255 No ................................................................... 749 2.
(25%) (75%)
(1%) (3%) (6%) (1%) (4%) (<1%) (3%)
Were you homeless at any time in the last 2 years? 3. (n=1015) 4. (23%) (77%)
Yes .................................................................. 237 No ................................................................... 778
What kind of help do you need to get housing or to keep your housing? (Check all that apply) (n=889) Dont need any housing assistance ......... 267 Help finding a roommate .......................... 55 Information or help to find affordable housing .............................................. 255 Help with moving ................................... 160 Help with paying rental deposit/s ........... 313 Small rental subsidy each month (like PARS) ....................................... 275 Housing with meals (HIV/AIDS group housing) .............................................. 79 Group housing for individuals with children................................................ 16 Group housing for people in recovery from drugs or alcohol .................................. 47 (30%) (6%) (29%) (18%) (35%) (31%) (9%) (2%) (5%) Group housing for people living with mental health issues.......................................24 Legal assistance.....................................134 Housing with personal care .....................31 Emergency shelter/hotel ..........................76 Job placement/vocational training .........195 Social support for substance use issues ...54 Mental health support............................117 Help with money management................75 Transportation .......................................231 More or better case manager contact & support ...............................................80 Low income housing .............................307 Help with paying rent (such as Section 8, TBRA, Shelter Plus Care) ...............382
(3%) (15%) (4%) (9%) (22%) (6%) (13%) (8%) (26%) (9%) (35%) (43%)
182
2010 Survey of People Living with HIV/AIDS (N=1,072 unless specified) San Diego County, April 2010 5. Family Needs Are you an adult taking care of a child or children under age 18? Yes ............................................................... 133 (11%) Are you caring for the child or children by yourself? (n=116) Yes ................................................................. 75 (65%)
How often do you feel that taking care of your family or children keeps you from going to the doctor or taking your medications? (n=116) Often ............................................................................6 (5%) Sometimes..................................................................30 (26%) Rarely ............................................................... 27 (23%) Never................................................................ 53 (46%)
Family Services (n=73) Services for Families Used this service in the last year 25 (34%) 17 (23%) 13 (18%) 12 (16%) 6 (8%) Need this service but cant get it 11 (15%) 25 (34%) 23 (32%) 22 (30%) 15 (21%)
Support groups for parents Housing for people with HIV and their children Support groups for children / teens Counseling services for my children / teens / family (emotional, mental health and grief counseling) Emergency housing for people with HIV and their children
183
6. Reported Risk Behaviors and HIV Prevention Needs HAVE YOU HAD SEX IN THE LAST 12 MONTHS? Yes:............................................................... 702 (70%) No:................................................................ 298 (30%) My relationship status: Single, no sex partners Single, one or some casual sex partners Have a primary partner but have multiple sex partners Have a primary partner who is my only sex partner
70 267 77 267
(10%) (40%) (11%) (40%)
How many people did you have sex with in the last 12 months? (n = 647): Response Average .83 8.2 .19 Response Total 191 4658 26 Response Count 231 568 135
# of female partners # of male partners # of transgender partners
Where did you meet your sex partners in the last 12 months? (check all that apply) (n = 627) No new sex partners:.................................... 166 Bars/clubs:.................................................... 133 Bathhouses: .................................................... 96 Coffee shops:.................................................. 48 Online/Internet: ............................................ 214 Parks:.............................................................. 65 Social parties:............................................... 100 Sex parties:..................................................... 44 Phone chat lines: ........................................... 42 Through friends:........................................... 184 Work:............................................................. 28 Other:............................................................. 71 (27%) (21%) (15%) (8%) (34%) (10%) (16%) (7%) (7%) (29%) (5%) (11%)
Have you had sex in any of the following locations in the last 12 months? (check all that apply) (n = 541) Bar: .................................................................27 Bathhouse: ....................................................109 Beach:.............................................................33 Bookstore: ......................................................47 Gym:...............................................................22 My home: .....................................................398 Others home: ...............................................262 Park: ...............................................................59 Restroom: .......................................................45 Rest stop: .......................................................10 Other:..............................................................27 (5%) (20%) (6%) (9%) (4%) (74%) (48%) (11%) (8%) (2%) (5%)
If you met your sex partners online, on which websites did you meet your sex partners? (check all that apply) (n = 215) adam4adam.com: .......................................... 171 barebackrt.com:............................................... 66 craigslist.com: ................................................. 82 gay.com:.......................................................... 30 manhunt.net:.................................................... 49 nudedudes.com: .............................................. 16 Other: .............................................................. 49 (80%) (31%) (38%) (14%) (23%) (7%) (23%)
184
Were any of your sex partners in the last 12 months (n = 595): YES 175 (29%) 135 (23%) 321 (54%) 253 (43%) 311 (52%) 219 (37%) 74 (12%)
Anonymous Bisexual Men who have sex with men HIV negative HIV positive or AIDS diagnosed Unknown HIV status People who shot up (injected) drugs, steroids, hormones, etc. In the last 12 months, did you ask your sex partners if they were HIV positive? (n = 635) Always:....................................................... 238 Sometimes: ................................................. 144 Never:.......................................................... 137 Not applicable: ............................................ 116 (38%) (23%) (22%) (18%)
In the last 12 months, did you ask your sex partners if they had an STD? (n = 622) Always: .......................................................175 Sometimes: .................................................119 Never: ..........................................................204 Not applicable: ............................................124 (28%) (19%) (33%) (20%)
In the last 12 months, did tell your sex partners that you are HIV positive? (n = 627) Always:....................................................... 318 Sometimes: ................................................. 139 Never:............................................................ 75 Not applicable: .............................................. 94 (51%) (22%) (12%) (15%)
In the last 12 months, did tell your sex partners if you had an STD? (n = 599) Always: .......................................................180 Sometimes: ...................................................61 Never: ............................................................90 Not applicable: ............................................268 (30%) (10%) (15%) (45%)
Did you use condoms when having sex with HIV negative persons? (n = 633) Always:....................................................... 287 (45%) Sometimes: ................................................. 161 (25%) Never:............................................................ 56 (9%) Not applicable: ............................................ 129 (20%)
Did you use condoms when having sex with person(s) who did not know if they were HIV positive or had and STD? (n = 616) Always: .......................................................253 Sometimes: .................................................134 Never: ............................................................67 Not applicable: ............................................162 (41%) (22%) (11%) (26%)
Did you use condoms when having sex with HIV-positive persons? (n = 627) Always: ......................................................... 199 Sometimes:.................................................... 154 Never:............................................................ 137 Not applicable: .............................................. 137 (32%) (25%) (22%) (22%)
185
Which substances have you used while engaged in sexual activity in the last 12 months? (check all that apply) (n = 536) Did not use substances while engaged in sexual activity: ...................................... 188 Alcohol:........................................................ 208 Cocaine/crack:................................................ 46 Ecstasy/other club drugs (GHB, K, LSD): ..... 47 Heroin: ........................................................... 14 HIV medication to enhance the effect of drugs or alcohol: ..................................... 10 Marijuana: .................................................... 132 Methamphetamine (meth, crystal):............... 121 Poppers: ....................................................... 132 Prescription drugs for recreational use:.......... 15 Prescription drugs for sexual performance, such as Viagra:........................................ 89 Other substance:............................................... 8
If you have used substances while engaged in sexual activity in the last 12 months, what were the reasons? (check all that apply) (n = 297) Have trouble meeting people when sober:.......40 No reason, didnt intend to have sex: ..............85 Partner wanted to:............................................80 Partying with friends: ......................................99 Sex feels better after using: ...........................111 Remove sexual inhibitions: .............................98 Out at a bar/club: .............................................65 Other reason: ...................................................27 (14%) (29%) (27%) (33%) (37%) (33%) (22%) (9%)
(35%) (39%) (9%) (9%) (3%) (2%) (25%) (23%) (25%) (3%) (17%) (2%)
Have you used meth or crystal while engaged in sexual activity in the last 12 months? (n = 547) Yes: ............................................................. 137 (25%) No: .............................................................. 410 (75%)
If you use meth or crystal while engaged in sexual activity in the last 12 months, how did you use it? (check all that apply) (n = 135) Ingest (eat):.................................................... 11 Inject (shoot up):............................................ 54 Insert into anus (booty bump): ....................... 32 Smoke: ......................................................... 112 Snort:.............................................................. 67 Other: ...............................................................3 (8%) (40%) (24%) (83%) (50%) (2%)
Have you injected drugs in the last 12 months? (n = 865) Yes: ............................................................... 70 (8%) No:............................................................... 795 (92%)
If you injected drugs in the last 12 months, have you shared needles or works in the last 12 months? (n = 71) Always:............................................................4 (6%) Sometimes: .................................................... 38 (54%) Never: ............................................................ 29 (41%) Which drugs were you using when you shared needles and/or works? (check all that apply)(n = 50) Cocaine:...........................................................5 (10%) Heroin:........................................................... 17 (34%) Hormones: .......................................................1 (2%) Meth: ............................................................. 41 (82%) Steroids:...........................................................2 (4%) Vitamins: .........................................................0 (0%) Other:...............................................................1 (2%)
How many people have you shared needles with? (n = 38) Average: .................................................................... 3.9
186
Please check the services(s) that you have received in the last year or currently would like to receive. (check all that apply) (n = 648): I RECEIVED THIS SERVICE IN THE LAST YEAR 385 (83%) 287 (74%) 93 (61%) 282 (75%) 180 (60%) 217 (65%) 284 (71%) I WOULD LIKE THIS SERVICE NOW 86 (19%) 108 (28%) 62 (41%) 105 (28%) 124 (41%) 121 (36%) 131 (33%)
Someone to talk with about the risk of passing on HIV or getting an STD Groups to address risk behaviors and learn safer ways of having sex HIV/STD education and information in jails HIV/STD education and information at community events HIV/STD education and information in social settings HIV/STD education and information on the internet Public announcements or materials in the community about HIV and STDs Would you like help to (n=870):
Prevent passing on HIV or getting an STD? (n = 854) Tell sex partners and/or needle-sharing partners about your HIV status? (n = 770) Address sexual compulsion or addiction? (n = 782)
YES 364 (43%) 216 (28%) 193 (25%)
NO 383 (45%) 453 (59%) 473 (61%)
NOT SURE 107 (13%) 101 (13%) 116 (15%)
187
188
APPENDIX J HIV PREVENTION FUNDING FY 2009/2010
189
190
APPENDIX J HIV PREVENTION FUNDING FY 2009/2010
Partner Services 11%
HIV Counsleing and Testing 33%
HIV Education and Prevention 56%
HIV Education and Prevention 1 HIV Counseling and Testing 2 Partner Services Total HIV Prevention Funds
1
$745,340 $437,435 $144,565 $1,327,340
Note: Additional one-time funding of approximately $250,000 for FY 2009/2010 provided by the County of San Diego to cover costs to providers incurred due to delays in the State budget. These funds will not be available in the future and are not included here for the future planning of services.
2
Note: Includes additional one-time funding of $100,000 for FY 2009/2010 for HIV counseling and testing targeting MSM provided by CDPH/OA. These funds will not be available in the future and should not be considered for the future planning of services.
191
HIV EDUCATION AND PREVENTION FUNDING CONTRACTED SERVICES BY REGION FY 2009/2010
Countywide 24%
North Inland and North Coastal Regions 12% South Region 12%
Central, North Central and East Regions 52%
North Inland and Coastal Regions Central, North Central and East Regions South Region Countywide Total Contracted Education and Prevention Funds1
1
$77,330 $326,871 $68,450 $150,000 $622,651
192
HIV EDUCATION AND PREVENTION FUNDING CONTRACTED SERVICES BY TYPE FY 2009/2010
Planning and Training 13%
Behavior Change Campaigns 13%
Health Education and Risk Reduction to High Risk Popluations 67%
Health Education and Risk Reduction Behavior Change Campaigns Planning and Training Total Contracted Education and Prevention Funds1
1
$ 420,851 $ 51,800 $150,000 $622,651
193
194
APPENDIX K GLOSSARY OF ACRONYMS
195
196
APPENDIX K GLOSSARY OF ACRONYMS ACRONYM AAAP ADS ARIES ART BCC BHS BRG C&T CBO CDC CDI CDPH/OA CHPG CLASP CofC CPG CRA CRCS DEBI E&P E&TP EBI eHARS EIS ELI FBWG FY GLI HCPI HCT HHSA HRBCC HRI HRSA HSHB IDU ILI LEO LGBT MEANING African American Gay Men/MSM HIV Prevention and Counseling and Testing Action Plan for San Diego County Alcohol and Drug Services AIDS Regional Information and Evaluation System Antiretroviral Therapy Behavior Change Campaign Behavioral Health Services Behavioral Risk Group HIV Care and Treatment Community-based Organization Centers for Disease Control and Prevention Communicable Disease Investigator California Department of Public Health/Office of AIDS California HIV/AIDS Planning Group Coalition of Latino AIDS Service Providers Continuum of Care Committee California Planning Group Community Readiness Assessment Comprehensive Risk Counseling and Services Diffusion of Effective Behavioral Intervention HIV Education and Prevention Epidemiology and Target Populations Committee Effective Behavioral Intervention Enhanced HIV/AIDS Reporting System Epidemiology and Immunization Services Evaluating Local Interventions Faith-Based Working Group Fiscal Year Group Level Intervention Health Communication Public Information HIV Counseling and Testing County of San Diego Health and Human Services Administration High Risk Behavior Change Campaign High Risk Initiative Health Resources and Services Administration HIV, STD and Hepatitis Branch of Public Health Services Injection Drug Users Individual Level Intervention Local Evaluations Online Lesbian, Gay, Bisexual, Transgender
197
ACRONYM LHJ LIG MSM OPR PAL PEP PIR Planning Council POD PrEP Prevention Board Prevention Group PS PS&E PwP QPR RFA RFP SAPT SOW STD TA TASC TPA YC
MEANING Local Health Jurisdiction Local Implementation Group Men Who Have Sex With Men Office of Performance Review Plan de Accin para Latinos: HIV Prevention and Counseling and Testing Action Plan for Latinos in San Diego County Post-exposure Prophylaxis Parity, Inclusion and Representation HIV Health Services Planning Council Prevention Outcome Database Pre-exposure Prophylaxis HIV Prevention Community Planning Board HIV Prevention Community Planning Group Partner Services Prevention Strategies and Evaluations Committee Prevention with Positives Quarterly Progress Report Request for Applications Request for Proposals Substance Abuse Prevention and Treatment Scope of Work/Statement of Work Sexually Transmitted Disease Technical Assistance Transgender Advocacy and Services Center Targeted Prevention Activity Youth Council
198
APPENDIX L GLOSSARY OF TERMINOLOGY
199
200
APPENDIX L GLOSSARY OF TERMINOLOGY Term Centers for Disease Control and Prevention (CDC) California Planning Group (CPG) Definition The federal agency dedicated to protecting the health and safety of people. The CDC funds a variety of HIV and STD prevention programs and initiatives. The CPG is a statewide planning group that provides community perspectives, advice and recommendations concerning HIV prevention and care and treatment to the California Department of Public Health, Office of AIDS (CDPH/OA). Funding the County of San Diego receives from the CDPH/OA for HIV education and prevention services.
Education and Prevention funds (E&P)
Epidemiology (EPI) The study of factors associated with health and disease and their distribution in the population. Incidence Incidence Rate The total number of new cases of a disease occurring within a specific period of time. The number of new cases of a disease occurring with a specific time period divided by the population at risk, often expressed per 100,000 population. Incidence rates are useful for comparison of selected factors to demonstrate the severity of the epidemic among individuals of different ages, gender and race/ethnicity group. A county or city defined by the CDPH/OA. The County of San Diego is a local health jurisdiction. The way in which a disease was passed from one person to another. In describing HIV/AIDS cases, this identifies how an individual may have been exposed to HIV, such as injection drug use or sexual contact. The annual number of deaths per 1000 people. AIDS cases who were newborns to children 12 years of age at time of diagnosis. The number of all cases (new and old) of a disease occurring within a specified period of time.
Local Health Jurisdiction (LHJ) Mode of Transmission
Mortality Pediatric Cases Prevalence
201
Term Prevalence Rate
Definition The number of all cases (new and old) of a disease occurring within a specified time period divided by the population at risk, often expressed per 100,000 population. Prevalence rates are useful for comparison of selected factors to demonstrate the severity of the epidemic among individuals of different ages, gender and race/ethnicity group. An ongoing, systematic collection, analysis, evaluation and dissemination of data regarding specific health conditions and diseases, in order to monitor these health problems. Calculating rates is generally a better indication of the burden of disease for a given population than just looking at raw numbers. A rate allows populations with dissimilar sizes to be compared. A rate is calculated by dividing the number of individuals with a disease in a given time period by the population size then multiply it by 100,000 to give the rate per 100,000 individuals. Rates by racial/ethnic groups are computed by dividing the number of individuals with AIDS from a race/ethnic group by the number of that group in the population at large. Formerly the Ryan White CARE Act and the Ryan White Treatment Modernization Act. The RWTEA was signed into law October 30, 2009 and extended previously authorized federal funding to improve the quality and availability of care for individuals infected/affected by HIV/AIDS four years through September 30, 2013. Statistical tests are used to determine when one rate is different than another and not due to random chance. Rates are described as statistically significant in the County of San Diego HIV/AIDS Epidemiology Report, when the rate can be said to be different from each other with 95 percent confidence (p<.05). The year in which a case met the CDC Criteria for AIDS and was diagnosed with AIDS. The year in which an AIDS case is reported to the Department of Health Services.
Public Health Surveillance Rate Calculation
Rates by Race/Ethnicity Ryan White Treatment Extension Act of 2009 (RWTEA)
Statistical Significance
Year of Diagnosis Year of Report
202
APPENDIX M HIV AND STD EDUCATION AND PREVENTION SERVICES BROCHURE
203
204
HIV EDUCATION AND PREVENTION

HIV Prevention Community Planning Group
Since 1995, the HIV Prevention Community Planning Group (Prevention Group) has been responsible for identifying and prioritizing HIV prevention needs and acts as an advisory committee to the HIV, STD and Hepatitis Branch of Public Health Services, the County Chief Administrative Officer and the Board of Supervisors. Our mission is to improve health, inclusive of sexual health, through risk reduction activities and prevent new HIV infections in the County.
2009 HIV EPIDEMIOLOGIC DATA
STD PREVENTION PROGRAMS

The STD Community Interventions Program (SCIP) works to increase capacity for youthserving organizations to integrate STD primary prevention into their existing programs and services. SCIP targets high morbidity areas of San Diego County to initiate community mobilization, provide trainings, and coordinate services. The Chlamydia Screening Project (ClaSP), interfaces education, screening, and treating female adolescents for chlamydia in juvenile detention facilities in San Diego County. inSpot.org/sandiego is a website that allows individuals who have tested positive for an STD to notify their partners via e-cards. inSpot.org provides people with a technology savvy, quick way to be responsible about notifying partners after learning of their STD status, which is particularly relevant in a time when more than ever before the Internet and technology are being used to initiate social and sexual connections.
Cum ulative HIV Cases of Men by Ethnicity in San Diego County
HIV and STD Education and Prevention Services
113; 3% 854; 25%
White Black Latino Other

363; 11% 2109; 61%
www.sdhivprevention.org
Cum ulative HIV Cases of Wom en by Ethnicity in San Diego County 15; 4% 121; 32% 134; 36%
White Black Latino

103; 28%
HIV, STD and Hepatitis Branch Public Health Services, County of San Diego For more information, please contact: Lori Jones Community Health Program Specialist lori.jones@sdcounty.ca.gov (619) 293-4755 Dan Uhler Program Support & Technical Assistance daniel.uhler@sdcounty.ca.gov (619) 293-4720 Jae Egan Planning Support & Technical Assistance jeffrey.egan@sdcounty.ca.gov (619) 692-8369
Other
Reported Mode of HIV Transm ission 9% 3% 6% 7%
The mission of the HIV, STD and Hepatitis Branch of Public Health Services (HSHB) is to plan and deliver quality medical and supportive services to improve health, inclusive of sexual health, addressing HIV, STD and hepatitis in diverse communities that are infected, affected and at-risk for these diseases, with an emphasis on the prevention of new infections in San Diego County. HIV, STD, & Hepatitis Branch Public Health Services
3851 Rosecrans Street PS 505 San Diego, CA 92110 Fax: (619)296-2688
For more information, please contact: Rose Ochoa STD Community Interventions & Chlamydia Screening Project Program Coordinator rosemari.ochoa@sdcounty.ca.gov (619) 293-4744
MSM MSM+IDU IDU Heterosexual Contact Risk not Specified

01/2010 County of San Diego, Epidemiology & Immunization Services, 2010
75%
County of San Diego HIV Education and Prevention Services

Family Health Centers of San Diego
www.fhcsd.org 4040 30th St, San Diego, CA 92104 Services in Central, North Central and East Regions Gay Mens Health Services: Serving gay men and men who have sex with men John Kua 619-515-2446 x2956 Injection Drug User Services: Serving injection drug users Catrina Flores 619-515-2438 Womens Program: Serving high-risk women Catrina Flores 619-515-2438 Project S.T.A.R. Serving the transgender community Tracie OBrien 619-515-2411 Brothers United: Serving African American men Harold Cooks 619-876-4464 Social Visions: Creation and coordination of social marketing and behavior change campaigns Victoriano Diaz 619-515-2589
San Diego Youth Services
www.sdyouthservices.org 3255 Wing Street, San Diego, CA 92110 Services in Central, North Central and East Regions The Storefront Shelter: 1-866-Place2Stay Serving high-risk youth Daniel Manson 619-325-3527
Service Type & Interventions

Targeted Prevention Activities (TPA) Contact through outreach on websites or in areas where individuals at highest risk for acquiring or transmitting HIV congregate. Group Level Interventions (GLI) Groups with individuals at highest risk for acquiring or transmitting HIV that include information, education, support and skills building to prevent the acquisition or transmission of HIV. Individual Level Interventions (ILI) Individualized health education and risk reduction counseling provided one on one for up to five sessions and may focus on multiple, complex problems and risk reduction needs. Partner Services (PS) Disclosure assistance to help HIV positive individuals disclose their HIV status in any of the following three situations: 1) on their own (selfdisclosure), 2) in the presence of a partner and counselor (dual disclosure), or 3) referral for third party notification in which the County of San Diego anonymously notifies partners of potential exposure to HIV. Health Communication Public Information (HCPI) - Presentations & Events: HIV prevention health information provided to high-risk groups at community events, health fairs and presentations in detention facilities. Social Marketing: HIV prevention health information provided to the public through social marketing and behavior change campaigns targeting high-risk populations.
Individuals at highest-risk for acquiring or transmitting HIV:

Persons of unknown status engaged in high-risk activities that have either never tested or have engaged in high-risk activities since their last test, including the window period HIV positive persons out-of-care and engaged in high-risk activities with someone of unknown status
San Ysidro Health CenterCASA

www.syhc.org 3045 Beyer Blvd, San Ysidro, CA 92173 Serving those at highest risk in the South Region Lucia Franco 619-662-4161 Para Program, Positiva/o Activa/o y Viva/o Marina Uribe 619-662-4161
San Diego County ranked HIV education and prevention priority populations:
1. Men who have sex with men (MSM; including men who also have sex with women and men of all ages, genders, races and ethnicities) 2. Injection drug users (IDUs; including IDUs of all ages, genders, races and ethnicities) 3. Partners of MSM and/or IDU (including partners of all ages, genders, races and ethnicities)
Vista Community Clinic

www.vistacommunityclinic.org 1000 Vale Terrace, Vista, CA 92084 Serving those at highest risk in the North Coastal and North Inland Regions Ashley Keller 760-631-5000 x213
Highest-risk activities
If within the past 12 months, an individual has: Had unprotected sex Used substances while engaged in sexual activity or through injection Had a sexually transmitted disease (STD)
Additional copies of this plan may be obtained at www.sdhivprevention.org or by contacting the HIV, STD and Hepatitis Branch of Public Health Services at (619) 692-8369.
Cover graphic designed by Tom Bingel

2010-2013 San Diego County Plan For HIV Prevention Services

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2010-2013 San Diego County Plan For HIV Prevention Services

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Plan for HIV Education and Prevention Services for San Diego County 2010-2013

Prepared by Jae Egan Lori Jones Dan Uhler

HIV, STD AND HEPATITIS BRANCH OF PUBLIC HEALTH SERVICES

Source: San Diego Association of Governments 2008 Population Estimates

Table 3 DISTRIBUTION OF THE GENERAL POPULATION BY RACE/ETHNICITY AND REGION, 2008

Race/Ethnicity Hispanic White Black Asian/Other* Total

% 13.0 62.8 3.3 20.9

% 27.6 57.2 2.0 13.2 100.0

% 29.9 50.2 5.3 14.6

Figure 1 FLOW OF ACCOUNTABILITY FOR HIV EDUCATION AND PREVENTION SERVICES

Figure 2 HIV EDUCATION AND PREVENTION COMMUNITY PLANNING GROUP STRUCTURE

County of San Diego Board of Supervisors

Date 04/12/10 05/10/10

As feasible, continue to provide risk reduction services

Lack of behavior change campaigns specifically targeting highest-risk youth

APPENDIX A GUIDING PRINCIPLES FOR EFFECTIVE HIV PREVENTION INTERVENTIONS

APPENDIX B HIV EDUCATION AND PREVENTION INTERVENTIONS AND STRATEGIES

APPENDIX C HEALTH BEHAVIOR THEORIES AND MODELS

Contemplation Preparation Action Maintenance

APPENDIX D HIV EDUCATION AND PREVENTION RESOURCE INVENTORY

Target Behavioral Risk Group

FHCSD HIV Services

TPA GLI ILI CRCS PS HCPI

African American and Latino MSM and all ethnic groups

HIV/AIDS service organization within a community clinic

Central East North Central South

The LGBT Center

GLI ILI CRCS HCPI PS

EBI Positive Action Sexual Health Groups

Latino and all LGBT

HHSA-HSHB-E&P (subcontractor of FHCSD) Private donations

CBO with non HIV/AIDS specific services

SAN DIEGO COUNTY HIV EDUCATION AND PREVENTION RESOURCE INVENTORY

San Diego Youth Services, HIV Services

TPA GLI ILI CRCS HCPI PS

All ethnic groups

Youth at high risk

HHSA-BH-ADS City of San Diego HHSA-HSHB-E&P

Multi-service agency with HIV/AIDS services

Central North Central East

Stepping Stone Positive Support Services

TPA GLI ILI CRCS PS HCPI

EBI First Things First Positive Support Services

HIV positive and all ethnic groups

San Ysidro Health Center

TPA GLI ILI CRCS PS HCPI

Latinos and all ethnic groups

HHSA-ADS HHSA-HSHB-E&P (subcontractor of FHCSD)

Harm reduction, substance abuse treatment and HIV services

Central North Central East

Community clinic with HIV/AIDS specific services

SAN DIEGO COUNTY HIV EDUCATION AND PREVENTION RESOURCE INVENTORY

Vista Community Clinic

TPA GLI ILI CRCS PS HCPI

All ethnic groups

Community clinic with HIV/AIDS specific services

North Coastal North Inland

Being Alive, San Diego

EBI New Beginnings HIV Support Groups Peer Advocacy

HIV positive with focus on MSM

HIV/AIDS service organization

TPA GLI ILI CRCS PS