Overview Populationswith Special NeedsHIV Planning CouncilNeeds Assessment CommitteeJune 16, 2010 Jan Carl Park, MA, MPA Nina Rothschild, MA, MPH, DrPH Source: NY EMA FY 2010 Part A Grant Application, October 30, 2009 www.nyhiv.org
Women of Color Photo Credit: www.caresource.org
Women of Color: Epidemiology The number of AIDS cases among women increased from roughly 21% in 1990 to 29% in 2008. Women account for 30% of PLWHA in the EMA, including 31% of new AIDS diagnoses in 2007-2008. Nine out of 10 women living with HIV/AIDS are women of color. Among women of childbearing age (ages 15-44), Blacks are nearly 15 times more likely than whites to be HIV-infected. The densest concentrations of female HIV/AIDS cases are in the City’s most impoverished neighborhoods – the South Bronx, Central Harlem, and Central Brooklyn. Women face unique challenges to health care access and continuity. Nearly one-third (29%) of NYC women diagnosed with HIV (non-AIDS) in 2007-2008 failed to enter care within three months of their positive HIV test.
Women of Color: CHAIN Study Women with HIV have particular health care and social service needs not typically shared with men, such as the need for appropriate gynecological services, child care and family-centered services. Women enrollees in CHAIN are more than twice as likely as heterosexual male study participants to experience domestic violence, which is associated with poor treatment adherence. Compared with other PLWHA participating in the longitudinal cohort study, HIV-infected women in CHAIN are significantly more likely to report lacking sufficient money in the household for utilities, food and clothing.
Women of Color: CHAIN Study Among HIV-positive women in the CHAIN study who need professional mental health services, 28-33% (depending on the location of the cohort – NYC or Tri-County) are not receiving them. Also depending on the location of the cohort, 46-52% of HIV-infected women in the study who require substance abuse services are not being served by such programs. Women living with HIV have an age-adjusted death rate that is 23% higher than their male counterparts. Women in NYC tend to be older than males when they are diagnosed with HIV, but on average they die at an earlier age.
Women of Color Between March and August 2009, HIV-infected mothers on average required 56% more Part A services than the typical PLWHA. Women with HIV/AIDS are particularly heavy users of home care, supportive counseling and family stabilization services. As many HIV-positive women have childrearing responsibilities, women used nearly two-thirds more food and nutrition services in the first half of 2009 than men.
Women of Color: Part A Funded Services Because women with HIV experience unique barriers to health care, the EMA invests in a range of women-focused initiatives that expand service access. While females represent 31% of all PLWHA in FY08, they accounted for 41% of Part A clients. Extrapolating from per-client estimates of expenditures, the EMA estimates that women represent more than $34 million in base Part A spending alone, including more than $8.5 million beyond the spending that would be anticipated if women represented the same percentage of Part A clients as they do of PLWHA overall.
Young Men of Color Photo credit: www.citadeloflove.org
Young MSM of Color: Epidemiology As of December 2008, 2,865 MSM of color between ages 13-29 were living with diagnosed HIV/AIDS in NYC. The rate of growth in this population is exceptionally high, with 1,163 young MSM of color having been diagnosed with HIV in 2007-2008. Young Black MSM (18-29) in NYC are nearly four times more likely than white or Hispanic MSM to be infected with HIV. From 2001 to 2008, HIV diagnoses among young MSM (under age 30) in NYC increased by 46%, with the number of new diagnoses rising by 68% among MSM ages 13-19.
Young MSM of Color Young MSM of color are often less likely than many other groups to use health care services. For example, because relatively few young people suffer from the chronic health conditions that are common in older adults, utilization of preventive, diagnostic and chronic disease management services may be a lower priority for young people. Most HIV-positive young MSM of color live in low-income neighborhoods, with a significant percentage residing in the Bronx, the country’s poorest urban county. Unemployment is high among young MSM of color, and opportunities for vocational training are typically limited. According to surveys conducted by DOHMH, young MSM of color frequently abuse drugs and alcohol, which may reduce treatment adherence and regular utilization of HIV primary care. A disproportionate share of the estimated 3,800 homeless young people in the EMA are MSM of color, and the chaotic life conditions associated with unstable housing significantly increase the risk of HIV infection and reduce utilization of needed services.
Young MSM of Color Many young MSM of color experience acute trauma and mental health challenges that may further diminish health care access. A recent multi-city survey of HIV-positive MSM (including in NYC) found that 47% reported having experienced childhood sexual abuse, with such abuse 2.6 times and 1.8 times as likely to be reported by Hispanic and Black MSM, respectively, as among whites. According to a nationwide survey of health departments and AIDS program officers, the stigma associated with homosexuality and discriminatory attitudes of providers frequently impede HIV service access for Black MSM.
Young MSM of Color: Services Because they face such severe impediments to favorable medical outcomes, young MSM of color have especially acute service needs. Among MSM diagnosed with HIV, Black and Hispanic men are more likely than whites to receive their AIDS diagnosis late in the course of infection. Compared to MSM overall, MSM of color are less likely to be in HIV care within three months of their HIV diagnosis.
Young MSM of Color: Part A Funded Services To address the growing epidemic among young MSM of color, Part A funds numerous programs that specifically address the unique needs of this population, including services for runaway youth and a clinic-based program in Manhattan for young MSM of color that returns an average of four clients a week to HIV primary care through intensive home visits and community outreach. The FY10 plan also includes an innovative new youth outreach initiative that will target young MSM and other high-risk youth, identifying people living with or at high risk of HIV under the age of 24 and linking them to care and treatment.
MSM: Epidemiology Nearly 35,000 MSM are living with HIV in the EMA. Since 2001, while the share of new HIV diagnoses among IDUs has fallen, the proportion of new HIV cases among MSM has steadily increased. In 2007-2008, MSM accounted for 44% of all new adult and adolescent HIV diagnoses in NYC. Among newly diagnosed MSM, roughly equal numbers of Blacks, Hispanics and whites are represented.
MSM: CHAIN Study 33% of MSM of color in the CHAIN study who need antiretrovirals were not accessing treatment. Three out of four (75%) MSM of color participants in the cohort study who need substance abuse services are not receiving them, while 69% of those requiring supportive mental health services are not utilizing such services. Forty percent of MSM of color who are homeless or unstably housed are not obtaining permanent housing assistance.
MSM: Part A Funded Services The intensive service needs of low-income MSM significantly increase the cost and complexity of the EMA’s HIV response. In 2008-2009, MSM accounted for 28% of EMA recipients of HIV uninsured care services, representing more than $55 million in outlays for HIV-related medications and physicians services (covered through a combination of Part A, Part B, and State tax levy). On average, MSM of color use 56% more Part A services, or $2,004 per client, than the average Ryan White client ($1,285).
MSM: Part A Funded Services MSM recipients of Part A services are predominantly Black and Hispanic. MSM of color are more likely than whites to be low-income and less likely to have private health coverage. The enduring stigma associated with homosexuality in many parts of the EMA, as well as limited primary care service options specifically designed for MSM of color, limits health care utilization by this group of high-need PLWHA.
Transgender Individuals Photo credit: www.uniter.ca
Transgender Individuals Transgender individuals represent another part of the broader lesbian/gay/bisexual/transgender (LGBT) community that faces heightened HIV risk and particular service challenges. An estimated 12,500 New Yorkers have undergone some form of medical gender transition. A recent meta-analysis of HIV-related studies involving transgender women (i.e., individuals who were assigned a male sex at birth but prefer a female identity) found overall HIV prevalence of 28% in this population, with consistently higher HIV prevalence detected among people of color.
Transgender Individuals The recently completed New York Transgender Project study found HIV prevalence of 50% among transgender women of Latin American origin and 48% prevalence among Black transgender women. In a DOHMH survey of NYC’s house ball community – which is 95% Black or Hispanic and includes considerable numbers of transgender individuals – 17% of study participants tested HIV-positive. Studies indicate that transgender women on average engage in higher levels of risk behavior – such as unprotected anal intercourse and injection drug use – than MSM. Transgender individuals are not only vulnerable to HIV infection as a result of unprotected sexual behavior, but also often as a result of needle sharing for the administration of hormones.
Transgender Individuals According to a recent survey of male-to-female transgender individuals in NYC, the shortage of transgender-friendly and transgender-knowledgeable health providers represent major barriers to care. Transgender individuals frequently suffer from homelessness or housing instability, lack of income, and harassment by law enforcement authorities.
Transgender Individuals: Part A Funded Services Part A supports programs specifically designed for MSM and transgender PLWHA and delivered by organizations grounded in these communities. Part A supports food and nutrition, treatment adherence and psychosocial support at a Manhattan-based agency with citywide reach that was founded by MSM. Part A supports the largest safety-net medical services provider in NYC’s LGBT community. Part A supports a contractor in the South Bronx which recently hired a transgender program coordinator to oversee outreach and the tailoring of services to reach low-income transgender PLWHA.
PLWHA Over 50 Photo credit: kday.tumblr.com
PLWHA Over 50: Epidemiology As a result of medical advances, PLWHA are living longer. In 2008, nearly 40,000 PLWHA in NYC were at least 50 years old. More than 11,000 PLWHA in NYC are older than 60, including more than 2,000 who are 70 or above. Between 2001 and 2008, the percentage of PLWHA who were 50 years or older rose from 21% to 37%. People older than 50 accounted for 25% of new AIDS diagnoses in NYC in 2008 and for 48% of all deaths among PLWHA. Three-quarters of PLWHA over 50 are Black or Hispanic, and older PLWHA are heavily concentrated in Lower Manhattan and in the low-income neighborhoods of Harlem and the South Bronx.
PLWHA Over 50: Epidemiology Older individuals also constitute an important and often under-recognized component of the newly diagnosed; in 2008, people over 50 represented 17% of new HIV diagnoses in NYC. Among newly diagnosed persons over age 50, 82% are Black or Hispanic. Older individuals are often diagnosed extremely late in the course of infection, frequently because they may lack an understanding of their vulnerability to infection. In 2007, 35% of newly diagnosed individuals ages 50-59, and 43% of newly diagnosed individuals over 60, were subsequently diagnosed with AIDS within one month of their positive HIV test. Even though newly diagnosed persons over 50 are typically much sicker than younger people who receive a positive HIV test result, nearly one in three (32%) persons over age 50 have still not entered HIV primary care within three months of diagnosis.
PLWHA Over 50 As PLWHA age, effective medical management of HIV requires the ability to manage conditions commonly associated with aging. Among PLWHA over age 50 who died in 2007, 44% died of a non-HIV-related cause (compared to younger AIDS deaths, 23% of whom died from non-HIV-related causes). The need to simultaneously manage HIV and numerous other health problems significantly increases the cost and complexity of care.
PLWHA Over 50: Part A Funded Services Barriers to care for PLWHA over 50 include insufficient access to providers capable of managing the comprehensive health problems of older adults, as well as the common problem of social isolation. In recent years, the EMA has made concerted efforts to focus services on PLWHA over age 50. Between FY06 and FY08, the number of clients over age 50 reached by Part A services increased by more than 50%, exceeding 19,000 in FY08. For HIV medications and primary services only – which are jointly funded by Part A, Part B, and State tax levy – PLWHA over age 50 accounted for an estimated $62 million in expenditures between April 2008 and March 2009.
Immigrants Photo credit: www.oregonlive.com
Immigrants: Epidemiology NYC is a major portal of entry to the U.S. and a primary destination for immigrants who enter the U.S. elsewhere. More than 21,000 PLWHA in the EMA – nearly one in five – are foreign-born. Infections among immigrants are rapidly rising. The percentage of new HIV diagnoses among foreign-born New Yorkers increased from 17% in 2001 to 27% in 2006.
Immigrants Immigrants living with HIV frequently confront overwhelming barriers to care. Often discouraged from seeking services due to language barriers or fear of deportation, many immigrants lack access to basic HIV/AIDS information. Linguistic barriers often impede health care access; according to a recent national survey, Spanish-speaking Hispanics have far worse access to care and medical outcomes than English-speaking Hispanics.
Immigrants In many immigrant communities, the stigma associated with HIV, homosexuality, and drug use deters individuals from seeking counseling, voluntary testing, or HIV/AIDS medical services. Isolation from friends and family frequently contributes to high levels of substance abuse and depression among immigrants, further interfering with healthy behaviors and service utilization.
Immigrants As a result of barriers to health care utilization, foreign-born individuals newly diagnosed with HIV in 2007-2008 were 50% more likely than their U.S.-born counterparts to receive an AIDS diagnosis within 31 days. Foreign-born newly diagnosed persons with HIV in NYC are also less likely than U.S.-born persons to have entered HIV primary care within three months of their diagnosis and are significantly more likely to be co-infected with TB than their US-born counterparts. Immigrant PLWHA have an age-adjusted death rate nearly one-third higher than white PLWHA.
Immigrants The large number of HIV-infected immigrants in the EMA increases the cost and complexity of responding to the epidemic. On average, HIV-positive immigrants used 33% more Part A services between March and August 2009 than PLWHA as a whole, representing an average per-client expenditure of Part A funds of $1,708 (compared to the average of $1,285 for all Part A clients).
Immigrants: Part A Funded Services To address the multiple barriers to health care access and continuity faced by diverse immigrant communities, Part A funds a broad range of services focused on immigrants living with HIV. Part A funds diverse services specifically designed for specific immigrant communities from the Caribbean, South America, sub-Saharan Africa, and Asia and the Pacific Islands. Part A funds service providers that have the capacity to deliver services in more than 50 languages. For HIV-positive immigrants who are undocumented, Part A is the sole source of funding for HIV care and treatment.
AOD Populations Photo credit: recovery.stantonstreet.com
AOD Populations The EMA uses federal, state and local funding to support a network of diverse alcohol and drug treatment services in the EMA. Such services include medically managed drug detoxification, adult outpatient services, intensive and community residential treatment, and drug substitution therapy (e.g., methadone, buprenorphine). Substantial unmet need exists for methadone maintenance, in-patient rehabilitation and residential services. In addition, many mainstream substance abuse treatment programs fail to address the unique medical and social needs of MSM, pregnant women, immigrants and other groups with high HIV prevalence.
AOD Populations To address the related epidemics of substance addiction and HIV/AIDS, the EMA in FY10 will allocate $12 million in base funding for client-centered, low-threshold substance abuse programs that are not covered by other payment sources. In FY10, Part A will support more than 17,000 PLWHA in addressing their substance abuse behaviors through harm reduction, recovery readiness and relapse prevention services.
AOD Populations More than three quarters (76.2%) of participants in the CHAIN study who received drug and alcohol treatment services in 2006-2007 reported being very satisfied with the quality of such care. For substance-using PLWHA enrolled in the CHAIN cohort, receipt of drug treatment is strongly associated with increased utilization of appropriate medical services.
AOD Populations: Part A Funded Services The EMA in recent years has increased its efforts to co-locate substance abuse services in settings that provide other essential services, such as primary medical care, housing assistance, and mental health services. For example, Part A supports physicians to provide substance abuse assessments and referrals to PLWHA living in single-room occupancy hotels. To address the unique needs of key sub-populations, Part A programs have implemented a range of innovative service models, including a Queens-based program for young PLWHA that uses recreational activities to attract clients to needed services.
Cultural and Linguistic Competence For foreign-born PLWHA, Part A funds an array of services in more than 50 languages. All Part A programs are required to have translation services available for non-English-speaking clients.