HIV/AIDS IN THE NATION’s CAPITAL IMPROVING THE DISTRICT OF COLUMBIA’S RESPONSE TO A PUBLIC HEALTH CRISIS Prepared by the DC Appleseed Center and Hogan & Hartson L.L.P.
AUGUST 2005 The cover art is an original artistic rendition by Leigh Cullen of the NAMES Project AIDS Memorial QuiltTM on the National Mall in Washington, D.C. Originally conceived in 1985, the Quilt consists of panels commemorating the lives of thousands of individuals who have died of AIDS. Each memorial panel is created and sewn by the individual’s friends and family members. The Quilt has been displayed in its entirety in Washington, D.C. four times, most recently in 1996 on the Mall. More information on the Quilt is available at http://www.aidsquilt.org/. The NAMES Project Foundation is not affiliated with DC Appleseed and had no involvement in the preparation of this report. HIV/AIDS IN THE NATION’s CAPITAL IMPROVING THE DISTRICT OF COLUMBIA’S RESPONSE TO A PUBLIC HEALTH CRISIS Prepared by the DC Appleseed Center and Hogan & Hartson L.L.P.
AUGUST 2005
COPYRIGHT © 2005 DC APPLESEED CENTER
ACKNOWLEDGMENTS
DC Appleseed thanks the Community Services Department at Hogan & Hartson L.L.P. for its invaluable participation in DC Appleseed's HIV/AIDS project. Hogan & Hartson attorneys – led by Pat Brannan (also a member of the DC Appleseed Board of Directors), Bob Leibenluft, and Veronica Valdivieso – have devoted over 4,000 pro bono hours assisting in the research and writing of this report. In addition, Robb Stout and Leigh Cullen of the Marketing Department at Hogan & Hartson provided assistance in the report's graphic design, layout, and production.
DC Appleseed would also like to thank its former Managing Director, Grace Lopes, for her efforts during the early stages of the HIV/AIDS project.
DC APPLESEED CENTER i This report was prepared with the input and advice of individuals who graciously agreed to donate their time as members of DC Appleseed's HIV/AIDS expert and stakeholder panels. DC Appleseed thanks all panel participants for their time and dedication. DC Appleseed also thanks Dr. Robert Washington for skillfully convening and facilitating the stakeholder panel and consumer focus groups.
Generous support for DC Appleseed's HIV/AIDS project was provided by the Washington AIDS Partnership, the Consumer Health Foundation, and the Annie E. Casey Foundation. General operating support for DC Appleseed is provided by the Fannie Mae Foundation, the Meyer Foundation, and the Morris and Gwendolyn Cafritz Foundation.
The DC Appleseed Center works on issues affecting the daily lives of those who live and work in the District of Columbia area – from health care to voting representation to education reform to environmental concerns to jobs and housing. We work with volunteer attorneys, business leaders and community experts to identify the issues, conduct research and analysis, make specific recommendations for reform, and advocate effective solutions. Our experienced staff organizes project teams and leverages thousands of hours of pro bono time.
Hogan & Hartson L.L.P. has been part of the Washington legal community for over 100 years. More than 30 years ago, Hogan & Hartson became the first major firm in the United States to establish a separate practice group devoted exclusively to providing pro bono legal services. The firm has been honored with such tributes as the American Bar Association's "Pro Bono Publico Award" and the District of Columbia Bar's "Pro Bono Law Firm of the Year Award." Through its 21 offices worldwide, the firm continues to contribute tens of thousands of pro bono hours each year.
ii HIV/AIDS IN THE NATION'S CAPITAL REPORT CONTRIBUTORS
REPORT PREPARED BY: Patricia Brannan, Hogan & Hartson Partner, DC Appleseed Board Member Robert Leibenluft, Hogan & Hartson Partner Josh Levinson, DC Appleseed Senior Program Associate and Communications Director Karen Schneider, DC Appleseed HIV/AIDS Project Director Dorothy Smith, DC Appleseed Program Associate Walter Smith, DC Appleseed Executive Director Veronica Valdivieso, Hogan & Hartson Associate
WITH MAJOR CONTRIBUTIONS FROM: E. Elizabeth Halpern, Hogan & Hartson Associate Audrey Moog, Hogan & Hartson Associate Monique Nolan, Hogan & Hartson Associate Deborah Spitz, DC Appleseed Deputy Director Lorrin Tuxbury, Hogan & Hartson Associate Aneta Wierzynska, Hogan & Hartson Associate
AND ADDITIONAL ASSISTANCE FROM:
Stefanie Berman, Hogan & Hartson Associate ACKNOWLEDGMENTS Nichelle Y. Johnson Billips, Hogan & Hartson Associate Katherine Broderick, DC Appleseed Board Member Gabriela Carias-Green, Hogan & Hartson Associate Edgar Cenon, Hogan & Hartson Resource Technician Alice Valder Curran, Hogan & Hartson Partner Renetta DeBlase, Hogan & Hartson Copyeditor Danielle Drissel, Hogan & Hartson Associate Robert Duncan, Hogan & Hartson Partner, former DC Appleseed Board Member Thomas Edman, Hogan & Hartson Associate Tammy Farmer, Hogan & Hartson Attorney Joshua Fershee, Hogan & Hartson Associate Patrick Fuller, DC Appleseed Legal Intern Daniel Gilman, Hogan & Hartson Associate Kimberly Greco, Hogan & Hartson Associate Katherine Hayes, Hogan & Hartson Associate Jacqueline Hodes, Hogan & Hartson Associate Amy Jiron, DC Appleseed Legal Intern Sheree Kanner, Hogan & Hartson Partner David Kassebaum, Hogan & Hartson Associate John Klempir, Hogan & Hartson Associate Jacob Leibenluft Edward Levin, DC Appleseed Board Member Robin Margolis, Hogan & Hartson Copyeditor Joseph May, DC Appleseed Legal Intern
DC APPLESEED CENTER iii Brian McCormick, Hogan & Hartson Associate Meg McKnight, Hogan & Hartson Associate Jeremy Monthy, Hogan & Hartson Associate Ryan Mooney, DC Appleseed Legal Intern Toni Moore Michaels, Hogan & Hartson Associate R. Mitchell Porcello, Hogan & Hartson Associate Jenny Rubin Robertson, Hogan & Hartson Associate Deborah Royster, DC Appleseed Board Member J. Patrick Runge, Hogan & Hartson Legal Assistant Chai Shenoy, DC Appleseed Legal Intern Rachel Sher, Hogan & Hartson Associate Beth Ann Thomas, Hogan & Hartson Legal Assistant Micul Thompson, Hogan & Hartson Associate Ruth Watson, Hogan & Hartson Health Specialist Deborah Weiner, Hogan & Hartson Associate April Wimberly, Hogan & Hartson Associate John Winterson, Hogan & Hartson Research Analyst
AND RESEARCH SUPPORT FROM THE FOLLOWING HOGAN & HARTSON SUMMER ASSOCIATES: Ebise Bayisa Sabrina Corlette Angela Howe Mona Jabbour Leslie Kendrick Emily Kimball Theodore Lotchin Sharese Pryor Elizabeth Rosenthal David Sewell Simon Stevens Robert Stolworthy Anna Rose Welch Darvin Williams
iv HIV/AIDS IN THE NATION'S CAPITAL DC APPLESEED STAFF AND BOARD
STAFF: Mary Jane Goodrick, Anacostia Watershed and River Restoration Project Director Chris Laskowski, Program Associate Josh Levinson, Senior Program Associate & Communications Director Desmond Riley, Director of Development Karen Schneider, HIV/AIDS Project Director & Lead in Drinking Water Project Director Dorothy Smith, Program Associate Walter Smith, Executive Director Deborah Spitz, Deputy Director Megan Stauble, Office Administrator
BOARD: Chair: Richard B. Herzog, Harkins Cunningham LLP Vice-Chair: Gary M. Epstein, Latham & Watkins LLP Vice-Chair: Roderic L. Woodson, Holland & Knight LLP Secretary: Lawrence R. Walders, Sidley Austin Brown & Wood LLP Treasurer: Peter D. Ehrenhaft, Miller & Chevalier Chartered Past Chair: Daniel M. Singer, Fried, Frank, Harris, Shriver & Jacobson LLP Past Chair: Nicholas W. Fels, Covington & Burling ACKNOWLEDGMENTS Patricia A. Brannan, Hogan & Hartson L.L.P. Katherine S. Broderick, UDC David A. Clarke School of Law Sheldon S. Cohen, Morgan Lewis Bert T. Edwards,CPA Curtis Etherly, Coca-Cola Enterprises Bottling Companies Rev. Graylan S. Hagler, Plymouth Congregational United Church of Christ James H. Hammond, Deloitte & Touche LLP Eric H. Holder, Jr., Covington & Burling Sheldon Krantz, DLA Piper Rudnick Gray Cary Edward M. Levin, Legal Consultant John W. Nields, Howrey LLP Beatriz Otero, CentroNia Gary Ratner, Citizens for Effective Schools, Inc. Alice Rivlin, The Brookings Institution Michael C. Rogers, MedStar Health Deborah M. Royster, RCN Corporation Lois J. Schiffer, Baach Robinson & Lewis PLLC Stanley M. Spracker, Levine School of Music
DC APPLESEED CENTER v
TABLE OF CONTENTS
EXECUTIVE SUMMARY ...... 1 INTRODUCTION ...... 2 SUMMARY OF REPORT ...... 3 HIV and AIDS Surveillance ...... 3 Funding and Grant Management ...... 4 HIV Prevention ...... 4 HIV/AIDS Treatment and Care ...... 5 HIV Prevention in the D.C. Public Schools ...... 5 HIV Prevention among Drug Users ...... 5 HIV/AIDS among the Incarcerated ...... 6 CONCLUSION ...... 6
DC APPLESEED CENTER vii REPORT STRUCTURE AND METHODOLOGY ...... 9 REPORT STRUCTURE ...... 10 Background of the HIV/AIDS Epidemic ...... 10 Findings and Recommendations Concerning the District's Response to the HIV/AIDS Epidemic ...... 10 METHODOLOGY ...... 11 Project Team ...... 11 Interviews and Site Visits ...... 12 Focus Groups ...... 12 Public Hearings, Meetings, and Events ...... 12 Document Review ...... 12 Benchmarking ...... 12 Vetting Process ...... 12 PART 1: BACKGROUND ON THE HIV/AIDS EPIDEMIC . . .13 I. HIV/AIDS EPIDEMIOLOGY ...... 15 INTRODUCTION ...... 16 HIV and AIDS ...... 16 Treatment of HIV/AIDS ...... 16 Modes of Transmission ...... 16 THE EPIDEMIC IN THE UNITED STATES ...... 18 THE EPIDEMIC IN THE DISTRICT OF COLUMBIA ...... 18 Modes of HIV Transmission in the District ...... 18 Risk by Population Group in the District ...... 21 CONCLUSION ...... 24 II. GOVERNMENT STRUCTURE ...... 27 THE FEDERAL GOVERNMENT ...... 28 THE DISTRICT OF COLUMBIA GOVERNMENT ...... 28 Department of Health ...... 29 Other Relevant District Agencies ...... 30 Committees ...... 30 CONCLUSION ...... 31 PART 2: FINDINGS AND RECOMMENDATIONS CONCERNING THE DISTRICT'S RESPONSE TO THE HIV/AIDS EPIDEMIC ...... 33 III. HIV AND AIDS SURVEILLANCE ...... 35 BACKGROUND ...... 36 Goals and Purposes of Surveillance ...... 36 HIV Surveillance ...... 36 Data Dissemination ...... 37 HIV/AIDS Reporting Requirements ...... 38 Data Storage and Protection ...... 38
viii HIV/AIDS IN THE NATION'S CAPITAL FINDINGS AND RECOMMENDATIONS ...... 38 Leadership and Resources of the Surveillance and Epidemiology Division ...... 38 HIV Surveillance ...... 39 Data Dissemination ...... 40 HIV/AIDS Reporting Requirements – Education and Enforcement ...... 41 Data Storage and Protection ...... 42 SUMMARY OF RECOMMENDATIONS ...... 42 CONCLUSION ...... 43 IV. FUNDING AND GRANT MANAGEMENT ...... 45 BACKGROUND ...... 46 Overview of Funding ...... 46 HIV Prevention Funding ...... 46 HIV/AIDS Health Care and Treatment Funding ...... 47 Grant Management ...... 50 Quality Assurance ...... 50 FINDINGS AND RECOMMENDATIONS ...... 50 Funding ...... 50 Grant Management ...... 52 Quality Assurance ...... 53 SUMMARY OF RECOMMENDATIONS ...... 54
CONCLUSION ...... 55 TABLE OF CONTENTS V. HIV PREVENTION ...... 57 BACKGROUND ...... 58 HIV Prevention Tools ...... 58 Advancing HIV Prevention (AHP) ...... 59 Testing and Counseling ...... 59 Condom Distribution ...... 61 Sexually Transmitted Disease Prevention and Treatment ...... 61 Prevention Case Management ...... 61 FINDINGS AND RECOMMENDATIONS ...... 62 Testing ...... 62 Condom Distribution ...... 63 Sexually Transmitted Disease Prevention and Treatment ...... 64 Prevention Case Management ...... 65 SUMMARY OF RECOMMENDATIONS ...... 65 CONCLUSION ...... 66 VI. HIV/AIDS TREATMENT AND CARE ...... 69 BACKGROUND ...... 70 Health Care Needs ...... 70 Case Management ...... 73 FINDINGS AND RECOMMENDATIONS ...... 73 Comorbidities ...... 73 Other Needs ...... 74
DC APPLESEED CENTER ix Case Management ...... 75 SUMMARY OF RECOMMENDATIONS ...... 75 CONCLUSION ...... 76 VII. HIV PREVENTION IN D.C. PUBLIC SCHOOLS ...... 79 HIV/AIDS AMONG YOUTH ...... 80 HIV PREVENTION IN DCPS ...... 81 The HIV/AIDS Education Program ...... 81 Health and Physical Education ...... 81 School Health Programs ...... 81 COMPONENTS OF A SUCCESSFUL HIV PREVENTION PROGRAM ...... 82 Curriculum ...... 82 Professional Development ...... 83 Collaboration and Coordination ...... 83 Monitoring, Data Collection, and Evaluation ...... 84 DCPS HIV/AIDS AD HOC COMMITTEE ...... 84 SUMMARY OF RECOMMENDATIONS ...... 85 CONCLUSION ...... 85 VIII. HIV PREVENTION AMONG DRUG USERS ...... 87 DRUG USE AND HIV/AIDS ...... 88 Background on Drug Use and HIV/AIDS ...... 88 Drug Use and HIV/AIDS in the District ...... 89 HIV PREVENTION STRATEGIES FOR DRUG USERS ...... 89 Community-Based Outreach ...... 89 Substance Abuse Treatment ...... 90 Access to Sterile Syringes ...... 90 SUMMARY OF RECOMMENDATIONS ...... 93 CONCLUSION ...... 94 IX. HIV/AIDS AMONG THE INCARCERATED ...... 97 HIV/AIDS AMONG THE INCARCERATED ...... 98 DETENTION FACILITIES IN THE DISTRICT ...... 99 The DOC and the Revitalization Act ...... 99 The D.C. Jail ...... 99 The Correctional Treatment Facility ...... 99 THE D.C. INMATE POPULATION ...... 99 HEALTH AND HIV/AIDS SERVICES AT THE D.C. JAIL AND THE CORRECTIONAL TREATMENT FACILITY ...... 99 HIV Prevention Services ...... 101 HIV/AIDS Treatment ...... 104 Discharge Planning ...... 104 Provision of HIV/AIDS Medication at Discharge ...... 105 DISCHARGE PLANNING FOR D.C. INMATES IN FEDERAL FACILITIES ...... 106 Discharge Planning by Our Place DC ...... 106
x HIV/AIDS IN THE NATION'S CAPITAL Discharge Planning by the Court Services Offender Supervision Agency ...... 106 REENTRY ISSUES FOR EX-OFFENDERS ...... 106 Services by Local Vendors in the District ...... 107 Services by CSOSA in the District ...... 107 SUMMARY OF RECOMMENDATIONS ...... 107 CONCLUSION ...... 107 CONCLUSION ...... 111 APPENDIX A ...... 113 LETTER FROM THE DEPUTY MAYOR APPENDIX B ...... 117 RECOMMENDATIONS APPENDIX C ...... 121 RECOMMENDATIONS FOR IMPROVING THE DISTRICT'S WEB-BASED HIV/AIDS RESOURCES HAA'S WEBSITE ...... 122 NON-GOVERNMENTAL WEB RESOURCE ...... 123
APPENDIX D ...... 125 TABLE OF CONTENTS THE DISTRICT’S HEALTH CARE COVERAGE PROGRAMS MEDICAID ...... 126 Eligibility ...... 126 Benefits ...... 128 ALLIANCE ...... 128 Eligibility ...... 128 Benefits ...... 129 RYAN WHITE ...... 129 Eligibility ...... 129 Benefits ...... 129
DC APPLESEED CENTER xi
EXECUTIVE SUMMARY
DC APPLESEED CENTER 1 District likely has one of the highest rates INTRODUCTION of new HIV infections. While the precise number of District residents infected with The District of Columbia's HIV is unknown, District public health response to the Human officials estimate that 1 out of every 20 District residents is infected. Even more Immunodeficiency Virus (HIV) alarming is the fact that thousands of these and Acquired Immune Deficiency individuals do not know that they are infected or that they may infect others. Syndrome (AIDS) epidemic lags In light of these circumstances, at the far behind that of many other request of the Washington AIDS Partnership and with the support of Mayor Anthony cities across the nation. Williams, DC Appleseed has examined how According to a high-ranking the District government is managing the city's HIV/AIDS epidemic – including efforts District official, the District is in to educate the public, prevent further spread of the disease, and care for infected some respects 10 to 15 years individuals. DC Appleseed attempted through behind where it should be in its investigation to address the question posed by Mayor Williams in an interview mounting a concerted, effective this spring: "We have huge incidence of response to the disease. Even HIV/AIDS. We spend a lot of money on it. How can we better focus our resources to though many individuals, get more mileage on something that's government officials, and killing too many people?" Unfortunately, as this report explains, there nonprofit organizations have are no simple answers to the Mayor's devoted considerable time and question. But several things are clear: z the District is not systematically collecting resources to addressing and analyzing data about the epidemic in a HIV/AIDS in the District, the way that would allow it to plan prevention and care effectively; disease continues to devastate z the District is not sufficiently coordinating District residents. and supervising the government agencies and private organizations that provide services for individuals living with The District's annual rate of new AIDS cases HIV/AIDS; is over 10 times the national average and is believed now to be the highest of any major z the District's general prevention efforts U.S. city. Through the end of 2003, need improvement; and approximately 16,500 District residents had z the District's HIV/AIDS services are been diagnosed with AIDS, resulting in over insufficient for certain populations, 7,000 deaths. Today, over 9,000 District including youth in the public schools, residents are living with AIDS. That is nearly drug users, and the incarcerated. 1 out of every 50 people in the District. In each of these four areas, this report Moreover, HIV/AIDS is one of the most makes specific findings and severe health problems facing the District, recommendations that, taken together, both in terms of disability and lost lives. should ameliorate the HIV/AIDS crisis facing Unfortunately, even these numbers fail to this city. Rather than calling for drastic capture the extent of the epidemic because government reorganization in order to they do not include HIV-positive people in improve the District's response to the the District who have not developed AIDS. HIV/AIDS epidemic, DC Appleseed suggests Given that the District's incidence of AIDS measures that can be implemented within is among the highest in the country, the the existing agency structure. DC Appleseed
2 HIV/AIDS IN THE NATION'S CAPITAL is mindful that there may be costs associated with some of the report's SUMMARY OF recommendations, although a number of the recommendations may be implemented REPORT without significant additional expense to This report is composed of two parts. the District. Where possible, DC Appleseed Part One provides information on the comments on the fiscal impact of its epidemiology of HIV/AIDS and the federal recommendations. and local government agencies that respond to the disease. Part Two consists of seven In addition, we believe an overarching chapters that make detailed findings and step needs to be taken – specifically, DC numerous recommendations about key Appleseed urges District leadership, aspects of the District's response to the including the Mayor, the City Administrator, epidemic. The first four chapters include the Deputy Mayor for Children, Youth, information on HIV and AIDS surveillance, Families, and Elders, and the Director of funding and grant management, prevention, the District's Department of Health (DOH), and treatment and care. The final three to clearly, forcefully, and publicly make the chapters discuss three populations that HIV/AIDS epidemic a top public health require additional specialized attention: youth, priority in the District. Such a step will help drug users, and the incarcerated. The main ensure that the necessary reforms occur and recommendations of these seven chapters will galvanize support within the government are as follows: and the community. Although DC Appleseed spent considerable HIV AND AIDS SURVEILLANCE time examining many factors essential to addressing the Mayor's question, we do not The District's HIV/AIDS Administration (HAA) should collect and publicly release
purport to have thoroughly investigated all EXECUTIVE SUMMARY the elements of the governmental response comprehensive HIV and AIDS data. The to the epidemic. In fact, there are significant dissemination of data – including the issues that merit in-depth review that could particular populations infected with HIV, how not be adequately addressed in this report, they became infected, and whether they including HIV/AIDS services for District suffer from other chronic illnesses – is critical residents in Wards 7 and 8, housing for to understanding the scope of the HIV/AIDS individuals living with HIV/AIDS, and the epidemic. Timely epidemiological data administration of the D.C. Healthcare Alliance provide the foundation for public health (Alliance) program. agencies to allocate funding and develop effective prevention and treatment DC Appleseed is grateful for the cooperation strategies. Unfortunately, the District's of the government and the community surveillance program has severe during the preparation of this report. In shortcomings. addition, DC Appleseed appreciates the feedback received from numerous First, the HIV test result data the District has government officials, health experts, collected for almost four years remain providers, and persons living with HIV/AIDS undisclosed. Although the District makes on the draft of the report. Everyone who public the number of District residents who reviewed the report expressed enthusiasm have developed AIDS and how these for working together to address the residents were originally infected with HIV, epidemic, including the Deputy Mayor for the District has not disseminated the HIV Children, Youth, Families, and Elders, as test result data. Because individuals infected noted in his letter attached in Appendix A. with HIV now can live ten years or more Finally, and most importantly, DC Appleseed before developing AIDS, HIV data more looks forward to working with the accurately reflect the current state of the government, providers, and others in helping epidemic than do AIDS data. Not having to implement the recommendations access to these crucial data handicaps policy contained in this report. makers who are responsible for HIV/AIDS prevention and care programs because, as noted above, the total number of District residents infected with HIV is unknown.
DC APPLESEED CENTER 3 Millions of dollars are being distributed HIV/AIDS in the District, Medicaid offers the for services and interventions based on best combination of services for beneficiaries outdated and incomplete data. and is the most cost-effective for the District. The Surveillance and Epidemiology Division Medicaid enrollment should therefore be (Surveillance Division) of the DOH's HAA, maximized. which is responsible for collecting and HAA should improve the management analyzing HIV/AIDS data and disseminating of its grants to private HIV/AIDS service epidemiologic profiles for the city, has providers. The District should improve its suffered from a lack of permanent leadership grant management process and use available and has a staff vacancy rate of greater than funding more efficiently. Chronic payment 50 percent. The absence of continuous, delays have hindered the provision of effective leadership and resources has had services by community-based organizations a significant negative impact on the (CBOs) and have put unnecessary financial Surveillance Division's ability to fulfill its pressure on these providers. The Council of responsibilities, including collection and the District of Columbia (D.C. Council) and dissemination of comprehensive HIV and the Office of the Inspector General (OIG) AIDS data. recently focused attention on this issue, and there are indications that HAA is streamlining FUNDING AND GRANT its grant payment process. HAA should MANAGEMENT ensure that grants are paid promptly and should evaluate the effectiveness of its new The District should improve coordination payment procedures on an ongoing basis. and supervision of funding for HIV/AIDS HAA should also address continuing services. Various publicly-funded programs problems with grant approvals and renewals provide financial assistance to cover the and burdensome reimbursement cost of certain HIV/AIDS services. These requirements that jeopardize the provision programs – which include Medicaid, the of HIV/AIDS services. Alliance, and specific programs for people living with HIV/AIDS such as the AIDS Drug Assistance Program (ADAP) – use separate HIV PREVENTION enrollment procedures, which can lead to HIV testing and counseling should be duplicate enrollment or failure to enroll offered as a routine part of all medical eligible individuals. care. The Centers for Disease Control and Prevention (CDC) estimates that almost one Enrollment difficulties and errors may disrupt quarter of those living with HIV nationwide the receipt of needed benefits and result in are unaware that they are infected. Studies inefficient use of funding resources. For indicate that individuals who know that they example, according to the District's Medical are HIV-positive are more likely to change Assistance Administration, in 2001, over their behavior to reduce the risk of 1,000 individuals were enrolled in both the spreading the infection to others and to Alliance and the District's Medicaid program. seek appropriate care and treatment for This type of duplicate enrollment needlessly themselves. More people likely would wastes the District's resources, since federal undergo HIV testing and learn their status funding should be covering the majority of if HIV testing were routinely offered as part the health care costs of these individuals. of medical care. Further, failure to enroll eligible individuals in programs such as ADAP can have severe DOH should promote routine HIV screening consequences. In fact, for many HIV-infected by all health care providers, including private individuals, enrollment in ADAP is the only doctors and medical facilities. The District way to receive and to pay for life-prolonging Medicaid program and the Alliance should HIV drugs. strongly encourage providers to offer HIV testing and counseling as a routine part of To avoid these problems, the District should primary medical care. DOH should develop a centralized application process for implement routine testing and counseling at enrollment and eligibility verification for its own health care facilities, including the publicly-funded health care programs. Of facilities serving high-risk populations such the programs available to persons with
4 HIV/AIDS IN THE NATION'S CAPITAL as substance abuse treatment facilities, the its outreach to high-risk and HIV-positive District's Sexually Transmitted Disease (STD) individuals. Clinic, and the Tuberculosis (TB) Clinic. All those tested should receive their HIV results HIV PREVENTION IN THE D.C. immediately to ensure that they know their PUBLIC SCHOOLS HIV status, take measures to change their behavior, and, if infected with HIV, enter D.C. Public Schools (DCPS) should appropriate treatment and care. develop and apply standards for HIV prevention education. Youth in the District HAA should significantly expand condom face serious risk of HIV infection due to distribution efforts. Condom use is one of above-average rates of unprotected sex and the most basic and universally recognized substance use. This risk is compounded by prevention interventions to reduce HIV the misconceptions young people often have transmission. When used correctly, condoms about health risks associated with HIV/AIDS greatly reduce the risk of transmitting and and methods to protect themselves from HIV contracting HIV. HAA should significantly transmission. District youth would therefore expand condom distribution efforts in the benefit from a more coordinated system of District, using a variety of venues, including HIV prevention education. Yet, there are government offices, health offices, and bars. currently no school-wide standards for the HAA should develop centralized mechanisms quality or content of HIV/AIDS education and for all providers of HIV/AIDS services to no means of tracking which students have obtain free or reduced price condoms. HAA received HIV/AIDS education. The Board of should also coordinate with District agencies Education and DCPS, in collaboration with serving high-risk populations, such as drug HAA, should develop system-wide users and the mentally ill, to develop a comprehensive standards regarding HIV system to increase condom availability
prevention education. EXECUTIVE SUMMARY among these groups. HIV PREVENTION AMONG HIV/AIDS TREATMENT DRUG USERS AND CARE The District should expand substance HAA should coordinate with agencies abuse treatment opportunities and serving HIV-positive individuals who also improve existing syringe exchange have other serious illnesses. People living programs. Available data demonstrate that with HIV/AIDS often suffer from other substance abuse treatment is a proven HIV diseases such as mental illness, drug prevention strategy. Injection drug users who addiction, hepatitis C, and TB. These other do not enter treatment are up to six times diseases may complicate HIV treatment, more likely to become infected with HIV than making HIV prevention and coordination those who enter treatment and do not of care even more problematic. resume drug use. The District's own reports Coordination between HAA and other have found that existing substance abuse relevant District agencies currently is limited, treatment programs do not meet the current and the lack of coordination can have severe demand of addicted individuals seeking consequences. For example, HIV testing is treatment. The District should increase the not routinely offered at all substance abuse availability of substance abuse treatment treatment facilities, the STD clinic, the programs. District's TB clinic, or sites serving individuals Further, injection drug users who share with mental illness. Individuals seeking care syringes and other injection equipment and and treatment at these facilities are more practice unsafe sex are at high risk of likely to be infected with HIV than others. contracting and spreading HIV and other Missed opportunities to inform individuals of blood-borne infections. Approximately one- their HIV status increases the risk of others third of the District's AIDS cases are being infected. By cooperating with agencies attributed to injection drug use. The District and providers serving individuals with estimates that there are approximately multiple illnesses, HAA could greatly improve 10,000 active injection drug users in the District today. Distributing sterile injection
DC APPLESEED CENTER 5 equipment, especially when done in others and also limits treatment options for connection with complementary services infected individuals. Because it may take a such as HIV testing and counseling, significant amount of time after release from prevention case management, and drug incarceration to locate a health care provider, treatment referrals, mitigates the adverse an inmate needs to receive a sufficient consequences of injection drug use by supply of medication at discharge. Currently, reducing HIV transmission. DOC provides only a 7-day supply of Although Congress has barred the District medication upon release. Federal funding is from using public funds to support the available to finance HIV medication for distribution of sterile injection equipment, inmates upon release. DOC should use HAA may lawfully fund complementary federal funds to increase the medication HIV/AIDS services provided by the existing supply provided at discharge. Unscheduled authorized syringe exchange program. HAA releases and poor internal communication should ensure that District-run programs and result in the release of inmates without CBOs that provide HIV/AIDS services medication. DOC should ensure that HIV- collaborate and co-locate with existing positive inmates are not released without syringe exchange programs – thereby adequate medication and a referral to a enhancing HIV prevention among the doctor; failure to do so puts both the recently District's drug users without violating the incarcerated and others at risk. congressional ban. Finally, the District government and advocates should continue efforts to persuade Congress to permit the use of local funds to support life-saving CONCLUSION programs that distribute sterile syringes. As Mayor Williams recently noted, the District has devoted significant resources to HIV/AIDS AMONG THE fighting HIV/AIDS – far more, in fact, than the INCARCERATED District has devoted to many other public health issues. Yet the District's annual AIDS The Department of Corrections (DOC) incidence continues to rise and is one of the should expand substance abuse highest in the nation. treatment programs for the incarcerated. The vast majority of incarcerated individuals On numerous occasions, the authors of this have a history of substance abuse, which report have asked key stakeholders in the puts them at high risk for HIV. Correctional District's system of HIV/AIDS care and facilities in the District offer a substance prevention how the HIV/AIDS epidemic has abuse treatment readiness program with a reached such massive proportions in the capacity for only 80 inmates, and a nation's capital. The answer to this question substance abuse treatment program that can was often the same: lack of effective, accommodate only 60 inmates. Since the consistent leadership. This lack of leadership District has over 3,400 inmates in custody in is evident in the following: local detention facilities on a daily basis, the z the true extent of the HIV/AIDS epidemic capacity of the substance abuse treatment in the District is unknown; programs is severely deficient. DOC should z HIV/AIDS services in the District are not expand its substance abuse treatment coordinated to the degree necessary to program as an HIV prevention measure. be effective; The DOC should ensure that HIV-positive z funding for HIV/AIDS prevention and care inmates receive a 30-day supply of HIV in the District is not being distributed in a medication when released from custody. It timely manner or being used as effectively is critical to the health of inmates on HIV and efficiently as possible; and medication that they continue their treatment regimen uninterrupted upon release. HIV z the District does not effectively target develops resistance to drugs rapidly, so poor services where they could make a adherence to HIV medication can result in an significant difference – among students, individual developing a drug-resistant form of drug users, and prisoners. HIV. Drug-resistant HIV can be transmitted to
6 HIV/AIDS IN THE NATION'S CAPITAL HIV/AIDS is a complicated disease both to can play a crucial role in educating the prevent and to treat. Controlling it takes community about the epidemic. But in more than money; it requires determination addition to raising awareness about and commitment from the government and HIV/AIDS, the Mayor, City Administrator, the community. The risk-taking behaviors that Deputy Mayor, and the Director of DOH lead to the transmission of HIV – sexual should take responsibility for ensuring that activity and drug use – are difficult behaviors HAA has the necessary staffing and to change but are not often discussed openly resources, is effectively managed, and by public officials. The reality is that the coordinates with other government agencies HIV/AIDS epidemic is getting worse in the to address the needs of special populations. District, not better. The District government Simply put, business cannot go on "as usual." should do more to address this crisis, and it The District's efforts to address HIV/AIDS has the tools at hand to do so. have fallen far short, and addressing the The District has a dedicated network of epidemic must move front and center as a providers addressing this disease and its priority of District government. devastating impact on our community. These With the appropriate attention and providers strive to educate, prevent, and commitment, the District can substantially treat those at risk for and infected with HIV. improve its response to this urgent public Their efforts deserve the unflagging support health issue. This report provides detailed of the government and the public at large. analysis and a list of specific District leaders are in a unique position to recommendations concerning the needed rally this support, and they should do so. response, but it is only the first step. DC DC Appleseed urges the leadership of the Appleseed is prepared to assist in the District to speak frequently, strongly, and implementation of the recommendations in this report, and to join with District leaders,
clearly about HIV/AIDS in our community EXECUTIVE SUMMARY and to take committed and strategic steps CBOs, and others in that effort. This disease to improve the management of this is not likely to be eradicated, but with the epidemic. This challenge is of life-and-death commitment and public support of District importance. Effective prevention, testing, leaders, we can reduce its terrible toll. and treatment of HIV/AIDS depend on an informed public, and government leaders
DC APPLESEED CENTER 7
REPORT STRUCTURE AND METHODOLOGY
DC APPLESEED CENTER 9 deficiencies in the District's system for REPORT STRUCTURE collecting, analyzing, and presenting timely The report is divided into two parts: surveillance data. (1) Background of the HIV/AIDS Epidemic z Chapter IV: Funding and Grant and (2) Findings and Recommendations Management. HIV/AIDS services are Concerning the District's Response to the funded by many agencies, including HIV/AIDS Epidemic. The report also includes the federal government, the District appendices containing a letter to the Project government, and private grants and Team from Deputy Mayor Albert, a list of donations. The chapter describes three recommendations, recommendations for critical publicly-funded programs: Medicaid, improving the District’s web-based HIV/AIDS the Alliance, and Ryan White CARE Act resources, and information regarding programs. Chapter IV also describes the eligibility requirements for certain publicly- challenges facing these programs and how funded health coverage programs in the the District's efforts to expand health care District. In addition, a list of acronyms is coverage for persons with HIV/AIDS have available on the back cover of the report. been hampered by poor coordination among agencies and inefficient use of PART 1: BACKGROUND OF THE funds. The chapter concludes by discussing HIV/AIDS EPIDEMIC HAA's grant management process and This part includes chapters on epidemiology the need for a comprehensive quality and government structure. assurance program. z Chapter V: HIV Prevention. Continuous z Chapter I: Epidemiology. The chapter examines current data about the HIV/AIDS surveillance of the epidemic and an epidemic in the District. understanding of relevant risk behaviors are necessary to formulate effective z Chapter II: Government Structure. The prevention interventions. Prevention chapter presents an overview of the efforts are a critical component of a federal and District agencies and comprehensive response to the HIV/AIDS programs, CBOs, and the health care epidemic. The chapter examines the providers that furnish prevention and care District's approach to preventing the services for HIV/AIDS in the District. spread of HIV, provides an overview of scientifically-tested HIV prevention PART 2: FINDINGS interventions, and describes prevention AND RECOMMENDATIONS programming. CONCERNING THE DISTRICT'S z Chapter VI: HIV/AIDS Treatment and RESPONSE TO THE HIV/AIDS Care. Many people living with HIV/AIDS EPIDEMIC struggle with multiple needs. Proper This part includes chapters on HIV and AIDS health care, housing, food, income, and surveillance, funding and grant management, transportation are particularly important in HIV prevention, and treatment and care. In order to effectively manage and treat addition, this part discusses HIV prevention individuals living with HIV/AIDS. However, in the public schools, HIV prevention for drug substance use and addiction, mental users, and HIV/AIDS among the incarcerated. health problems, limited access to health care and support services, and poverty z Chapter III: HIV and AIDS Surveillance. often result in these needs being unmet. Surveillance is the means by which public The chapter describes the care and health agencies track the incidence of HIV services required by individuals living and AIDS. Incidence data are necessary with HIV/AIDS and the type of services to allocate federal and local funding and provided by the District. to formulate effective treatment and prevention strategies. Chapter III provides z Chapter VII: HIV Prevention in D.C. background information on HIV and AIDS Public Schools. Many young people have surveillance in the District. The chapter misconceptions about the health risks highlights the importance of surveillance associated with STDs and HIV/AIDS, as data and analysis and identifies current well as incomplete or erroneous
10 HIV/AIDS IN THE NATION'S CAPITAL information on prevention measures and writing of this report. Hogan & Hartson the need for testing. Therefore, a targeted provided its services pro bono. Because and comprehensive HIV prevention of existing relationships in its education program is imperative to provide young practice, Hogan & Hartson did not assist in people with the skills and information to the research or drafting of the chapter on protect themselves. The chapter describes HIV Prevention in the D.C. Public Schools. the HIV prevention programs that exist In addition, DC Appleseed convened an within the D.C. Public Schools (DCPS) and expert panel and a stakeholder panel to makes recommendations to strengthen advise the Project Team in conducting these programs. research and formulating findings and z Chapter VIII: HIV Prevention among recommendations. Drug Users. Research has shown that the most effective approach for preventing the EXPERT PANEL spread of HIV in drug-using populations The members of the expert panel, who is a comprehensive strategy that includes participated in the project pro bono, are: community-based outreach, drug abuse Nicole Lurie, M.D., M.S.P.H., a physician/ treatment, and sterile syringe access researcher at RAND Corporation; Dr. Charles programs – all in combination with testing Turner, Ph.D., a behavioral scientist with the and counseling for HIV. The chapter City University of New York and the Research includes recommendations for the Triangle Institute; Mary Young, M.D., Director improvement of substance abuse of the Women's Integrated HIV Study at the treatment and HIV prevention services Georgetown University Medical Center; and among the District's population of drug Jonathan Zenilman, M.D., Chief of Infectious REPORT STRUCTURE AND METHODOLOGY users. Diseases at Johns Hopkins Bayview Hospital. z Chapter IX: HIV/AIDS Among the The Project Team also consulted with Tim Incarcerated. The rate of AIDS cases Westmoreland, J.D., Research Professor at among the incarcerated in the U.S. is the Georgetown University Health Policy three times higher than the AIDS rate Institute. among the general population in the United States. The incarcerated are STAKEHOLDER PANEL isolated from the mainstream system With the assistance of Robert Washington, of prevention and care while they await Ph.D., a psychologist and former Director of trial or serve their sentences. Detention the District's Department of Mental Health presents an opportunity for targeted (DMH), DC Appleseed convened and prevention and care services prior to their facilitated a stakeholder panel that included release to the community. The chapter representatives from the following groups: explains HIV/AIDS services for the HIV-positive individuals; HIV/AIDS service incarcerated and ex-offenders in the providers; mental health providers; HIV District and makes recommendations prevention services organizations; faith-based for improving these services. organizations; and advocacy groups for the incarcerated, transgender community, and sex workers. A number of the stakeholders are employed by organizations that receive METHODOLOGY funding from HAA. The panel has been DC Appleseed, an advocacy organization that instrumental in informing DC Appleseed's addresses serious local issues, organized a research and writing. The following is a list Project Team to research and analyze the of panel members: District's response to HIV/AIDS and prepare z Jeffrey Akman, M.D., Chairman, this report. Department of Psychiatry and Behavioral Sciences, George Washington University
PROJECT TEAM z Philippe Chiliade, M.D., Medical Director, A team of volunteers at the law firm of Whitman-Walker Clinic Hogan & Hartson L.L.P. partnered with DC Appleseed to conduct the research and
DC APPLESEED CENTER 11 z Lawrence D'Angelo, M.D., M.P.H., Interviews with District government Division Chief, Adolescent Medicine, officials and representatives from Children's National Medical Center community organizations are referenced on an anonymous basis in the report. z Philip Fornaci, J.D., Executive Director, D.C. Prisoners' Legal Services Project
z Earl Fowlkes, Executive Director, DC FOCUS GROUPS CareConsortium The Project Team conducted various focus groups with HIV-positive individuals and drug z Susan Galbraith, Executive Director, users. These groups included individuals of Our Place DC various age groups and different genders, z Robert Keisling, M.D., Director of Mental as well as a cross-section of income levels. Health, Unity Health Care z Bernadine Lacey, RN, Ed.D., Former PUBLIC HEARINGS, MEETINGS, Executive Director, Children's School AND EVENTS Services, Children's National Medical Center In order to obtain a broader understanding of issues involved, the Project Team z Patricia Nalls, Executive Director, attended numerous public hearings and The Women's Collective meetings, including Congressional hearings, z Candace Shultis, Pastor, Metropolitan D.C. Council hearings, meetings of the Community Church Mayor's Advisory Committee for HIV/AIDS, HIV Prevention Community Planning Group z Catalina Sol, Director, HIV/AIDS Program, La Clinica del Pueblo meetings, Ryan White Planning Council meetings, World AIDS Day events, public z Adam Tenner, Executive Director, roundtable meetings, and community Metro Teen AIDS events. z G.G. Thomas, Client Advocate & Program Assistant, Helping Individual Prostitutes DOCUMENT REVIEW Survive The Project Team reviewed thousands z Jay White, Board of Directors, of pages of documents, including reports, Us Helping Us legislation, budgets, studies, policies, z Christine Wiley, Pastor, Covenant and meeting minutes. Baptist Church BENCHMARKING INTERVIEWS AND SITE VISITS Where appropriate, the Project Team The DC Appleseed HIV/AIDS Project Team identified model practices in other interviewed approximately 150 individuals, jurisdictions. When pertinent, these are including Gregg Pane, M.D., Director of identified in the body of the report. DOH, Lydia Watts, Director of HAA, and virtually all division heads at HAA. The VETTING PROCESS Project Team also met with officials from DC Appleseed received comments on the Addiction Prevention and Recovery drafts of this report from numerous Administration (APRA), DCPS, the DOC. In individuals, including members of the Project addition, the Project Team also interviewed Team's expert and stakeholder panels, the numerous providers, consumers, public DC Appleseed Board of Directors, District health experts, and advocates who work government officials, members of the D.C. directly with persons living with and at risk Council, and other interested individuals and for HIV and AIDS in the District. Finally, the organizations. The content of the final report Project Team toured the facilities of many reflects feedback from these individuals. care and prevention service providers.
12 HIV/AIDS IN THE NATION'S CAPITAL PART 1 BACKGROUND ON THE HIV/AIDS EPIDEMIC
PART 1: CHAPTER I HIV/AIDS EPIDEMIOLOGY
CHAPTER INFORMATION: INTRODUCTION Modes of HIV Transmission Youth in the District HIV and AIDS Transgender Individuals Sexual Contact Senior Citizens Treatment of HIV/AIDS Men Having Sex with Men CONCLUSION Modes of Transmission Heterosexual Contact Sexual Contact Prostitution, Survival Sex, Substance Use and Abuse and the Sex-for-Drug Trade Mother-to-Child Transmission Sexually Transmitted Diseases Blood Transmission Substance Use and Abuse Contaminated Needles Mother-to-Child Transmission THE EPIDEMIC IN THE Risk by Population Group UNITED STATES in the District THE EPIDEMIC IN THE People of Color DISTRICT OF COLUMBIA Women Incarcerated Individuals
DC APPLESEED CENTER 15 Before examining the system of three months after infection, and nearly all of those infected develop antibodies within care and prevention for HIV/AIDS six months. in the District, it is necessary When an HIV-positive individual's CD4+ T-cell count falls below 200 per cubic millimeter of to outline the magnitude of the blood (the normal range is 600 to 1,200), the problem. After explaining the individual meets the CDC's clinical definition for AIDS.3 If an HIV-positive individual is epidemiology of HIV and AIDS, diagnosed with one of 26 clinical conditions listed by the CDC, including certain types of this section describes the pneumonia, he or she also meets the AIDS epidemic, both on a national definition.4 and local level, in terms of TREATMENT OF HIV/AIDS common modes of transmission Recommended care for HIV-positive and high-risk populations. individuals changed dramatically in 1996, with the development of "highly active antiretroviral therapy" (HAART), a treatment that combined existing medications with new 1 INTRODUCTION drugs that interfere with the replication of the virus.5 Prior to the introduction of HAART, the CDC estimated that about half of the HIV AND AIDS HIV-positive population would develop AIDS HIV is a virus that damages and kills within 10 years after infection with the virus.6 an infected individual's immune cells, The progression time varies greatly across particularly the CD4+ T-cells, which individuals due to a variety of factors, coordinate the body's immune response. including pre-existing health status and About 70 percent of newly-infected people behaviors.7 With the introduction of HAART, will experience initial symptoms similar to the onset of AIDS in individuals infected those of the flu: fevers, chills, night sweats, with HIV has been significantly delayed.8 and rashes, which usually last for a few days. Within three to five days after infection, MODES OF TRANSMISSION the virus travels to the lymph nodes, where HIV is transmitted through the exchange of it reproduces rapidly. As HIV progressively certain body fluids, including semen, vaginal destroys the immune system, the body secretions, breast milk, and blood. The becomes vulnerable to opportunistic major transmission modes are sexual contact infections – caused by viruses and bacteria (either homosexual or heterosexual), the that are typically not harmful to people sharing of syringes or other drug-injection with healthy immune systems – as well equipment, mother-to-child transmission, as to certain cancers.2 and blood transfusions.
Indicators of AIDS: SEXUAL CONTACT HIV infection with The most common mode of HIV 9 z Low CD4+ T-cell count transmission is sexual contact. Some types of sexual contact, such as unprotected z Specific diseases and conditions indicative of AIDS, such as receptive anal sex, present a greater risk of certain types of pneumonia transmission of the virus than others. For all sex acts, however, proper condom use has been shown to reduce the risk of contracting Individuals with HIV are identified by testing HIV.10 The greater number of partners a for the presence of HIV antibodies, special person has, the greater is the exposure to proteins produced by the immune system to potential HIV infection, particularly if safe sex fight the disease. About 95 percent of people practices are not employed with each sex infected with HIV develop antibodies within act. Safe sex involves the use of condoms
16 HIV/AIDS IN THE NATION'S CAPITAL during vaginal and anal sex and a protective have found alcohol use increases two latex barrier between the mouth and the to fourfold the likelihood of not using vagina, penis, or anus during oral sex. condoms.20 If a person is already infected with an STD, the chances of contracting HIV are higher. MOTHER-TO-CHILD TRANSMISSION The increased risk of HIV infection may be Mother-to-child HIV transmission is almost due to the fact that an individual with an entirely preventable. If untreated, about one STD is engaging in unsafe sex, or may be quarter to one third of HIV-positive women because STDs such as syphilis, chlamydia, will transmit the virus to their babies during and gonorrhea appear to increase the body's pregnancy or labor and delivery through vulnerability to HIV.11 The increased risk of mechanisms that remain unknown, or after transmission may be due to open sores or birth through breastfeeding.21 However, breaks in the skin, as in the case of syphilis, medical treatment exists that can or because of other effects of the STD.12 dramatically reduce this transmission rate. STD infections in HIV-positive individuals may With combination antiretroviral therapy and increase the viral load in the HIV-positive use of caesarean section when necessary, person's secretions, resulting in a greater the risk of mother-to-child transmission is risk of transmitting the disease to others.13 lowered to 1 to 2 percent.22
SUBSTANCE USE AND ABUSE BLOOD TRANSMISSION Substance use and abuse are linked with the Historically, individuals receiving blood transmission of HIV in two ways: through transfusions were at risk for HIV. Today, blood the sharing of needles and syringes infected supplies are routinely screened for HIV, and HPE :HIV/AIDS EPIDEMIOLOGY CHAPTER I: with the virus, and through high-risk sexual pooled blood products are treated with heat behavior associated with the use of alcohol to destroy the virus, rendering the likelihood or drugs.14 of transmission through transfusions to about 1 in 1.5 million.23 Needle and syringe sharing can lead to exchange of blood and thus result in Some risk of transmission through blood transmission of the virus.15 Studies have exchange still exists in certain situations. shown that HIV can survive in used needles For example, if an individual has a bleeding for over one month.16 The relationship cut in the mouth or the genital area, he or between injection drug use and HIV infection she is susceptible to HIV infection from an goes beyond the substance users and puts HIV-positive individual who also has a others at risk for contracting the disease. bleeding cut. Similarly, an emergency worker For example, an injection drug user (IDU) can spread the infection to a sexual partner Myths through unprotected sex and a pregnant IDU may pass HIV to her fetus.17 Some people erroneously believe the following: Substance users are also at a higher risk for HIV can be transmitted by: engaging in survival sex and sex for drugs, z Saliva which may put them in greater danger of z Sweat infection. Survival sex refers to the practice of selling one's body to obtain the basic z Tears necessities of life, such as food and shelter. z Urine Substance users may also engage in sex z Feces work in order to obtain drugs and may HIV can be cured or prevented by: forego the use of condoms during sex. z Drinking a bottle of vinegar Another risk factor for unprotected sexual behaviors and, consequently, HIV z Exercising regularly transmission, is alcohol use.18 Studies of z Eating garlic homosexual men have found an association between heavy alcohol use and increases in National Institute of Allergy and Infectious Diseases, HIV Infection and AIDS: An Overview high-risk sexual behavior or decreases in (Mar. 2005). condom use.19 Among heterosexuals, studies
DC APPLESEED CENTER 17 with an open cut could be exposed to delay of the onset of AIDS, current AIDS an HIV-positive individual with a bleeding data do not shed light on the incidence of wound. HIV transmission can also occur, recent HIV infections, particularly among very rarely, through accidental needle those whose progression to AIDS may be sticks in a health care setting.24 slowed by antiretroviral therapy.30 Thus, a comprehensive picture of the epidemic and a CONTAMINATED NEEDLES realistic estimate of the resources needed Contaminated needles used for steroids, for care and services cannot be provided silicone, and other injections may, as in the without HIV prevalence and incidence data; case of needle sharing by IDUs, lead to HIV nevertheless, the existing AIDS prevalence infection. In addition, use of infected needles and incidence data do suggest that the for tattooing and piercing may lead to District HIV rates are likely to be extremely transmission of HIV.25 high when compared to other cities nationwide. In the most recent year for which data are available, the District had the highest THE EPIDEMIC incidence of AIDS of all major metropolitan areas in the U.S. In 2003, the District had an IN THE UNITED AIDS incidence rate of 170.6 per 100,000 people.31 This is an increase from the STATES District's AIDS incidence rate in 2001, which The CDC estimates there have been a total at 119 cases per 100,000 people was the of 929,985 reported cases of AIDS in the highest rate among cities with populations U.S. from 1981 through 2003, of which an over 500,000.32 In 2001, Baltimore had a estimated 524,060 resulted in deaths comparable rate of 117 per 100,000, followed attributable to AIDS.26 An estimated 1.1 by San Francisco (67 cases per 100,000), million individuals are presently infected with New York (64 cases per 100,000), and HIV in the U.S.,27 of which as many as one Philadelphia (58 cases per 100,000).33 Such quarter may be unaware of their infection.28 comparative information is not available for According to the CDC, of those infected with more recent years. HIV, 405,926 people were living with AIDS According to the District's DOH, 9,375 in the U.S. in 2003.29 individuals were living with AIDS in the District as of December 31, 2003.34 There Definitions: have been over 7,000 AIDS-related deaths 35 z Prevalence = proportion of persons with a particular disease in the District since 1984. Similar to the within a given population at a given time national trend, the number of AIDS-related deaths in the District has been declining z Incidence = rate of new cases in a population during a for the last 10 years, from its peak of 742 specified time period deaths in 1993 to 41 deaths in 2002.36 The decreased number of deaths is attributable Clinical Epidemiology Glossary, available at http://www.med.ualberta.ca/ebm/define.htm (last visited to the increased use of antiretroviral July 23, 2005); D. Coggon et al., EPIDEMIOLOGY FOR THE UNINITIATED (4th ed. 1997), available at http://bmj.bmjjournals.com/epidem/epid.2.html (last visited July 23, 2005). medication, which slows the progression of HIV to AIDS and lengthens the average time a person can survive with AIDS.37 Despite advances in treatment, HIV/AIDS is one of THE EPIDEMIC the most severe health problems facing the District, both in terms of disability and lost IN THE DISTRICT lives.38 OF COLUMBIA MODES OF HIV TRANSMISSION The District's AIDS rate has been estimated IN THE DISTRICT to be among the highest of urban areas in the country. As will be further explained in Sexual contact is the most commonly Chapter III, the District does not currently reported mode of HIV transmission in the publicly disseminate HIV data. Due to the District. Injection drug use also plays an
18 HIV/AIDS IN THE NATION'S CAPITAL HPE :HIV/AIDS EPIDEMIOLOGY CHAPTER I:
District of Columbia Department of Health, The HIV/AIDS Epidemiologic Profile for the District of Columbia 1 (Dec. 2003).
important role in transmission in the District. African-American and Latino MSM are A significant number of persons living with impacted by HIV/AIDS. Forty-six percent of AIDS are unaware of how they contracted African-American men with AIDS contracted HIV.39 HIV through male-to-male sexual contact.41 For Latino men, that figure is 62 percent.42 Transmission Trends in Factors such as poverty and inadequate the District access to health care can reduce access to prevention services, particularly for men of z Heterosexual contact is increasingly color.43 Moreover, African-American and being identified as a mode of Latino MSM are less likely than white MSM transmission, as is the case nationwide. to be tested for HIV or to seek treatment through programs targeting the homosexual z The AIDS rate among women has 44 been increasing. and bisexual communities. z HIV continues to disproportionately HETEROSEXUAL CONTACT affect people of color, particularly Both men and women can contract HIV African Americans. through heterosexual contact. Among the 2,028 women living with AIDS in the District in 2002, 44 percent identified heterosexual SEXUAL CONTACT contact as their mode of exposure.45 Many national studies indicate that the increase in MEN HAVING SEX WITH MEN the rate of HIV/AIDS among women may be Men having sex with men, or MSM, are due, in part, to the fact that many women at high risk for HIV. Male-to-male sexual are not aware of the high-risk behaviors of contact is the most common mode of HIV their sexual partners, meaning the sex or transmission in the District.40 drug-use behaviors that may directly transmit
DC APPLESEED CENTER 19 PROSTITUTION, SURVIVAL SEX, AND THE MSM: "Men having sex with men" SEX-FOR-DRUG TRADE MSM include men who have sex with men but identify Commercial sex work, the exchange of sex themselves as heterosexual, as well as men who identify for basic life necessities, and the exchange themselves as homosexual or bisexual. of sex for drugs also have been linked to HIV infection.47 Estimates of the number of Men on the "down low" individuals involved in these activities in the District are unavailable. The media report that, facing a stigma surrounding homosexuality in their communities, MSM may identify as heterosexual and SEXUALLY TRANSMITTED DISEASES conceal their sexual activity with men. These men, who are STDs are important indicators of risky sexual "on the down low," may continue to have unprotected sex with behavior and are likely to be significantly their girlfriends or wives, thus placing those women at risk for underreported. As is the case nationwide, HIV infection. The "down low" phenomenon likely occurs among there has been a slight increase in rates of all races, and no scientific studies were found regarding its syphilis, chlamydia, and gonorrhea in recent involvement in HIV transmission among any group. years in the District, particularly among men.48 The incidence of these STDs See, e.g., Benoit Denizet-Lewis, Double Lives on the Down Low, N.Y. TIMES, Aug. 3, 2003, § 6 continues to be far higher in the District (magazine), at 28; Jose Antonio Vargas, HIV-Positive, Without a Clue, WASH. POST, Aug. 4, 2003, than in the nation overall.49 The high STD at B1. incidence among certain populations suggests continued engagement in high-risk HIV.46 Some women believe they are in a behavior, and also may reflect increased monogamous relationship and do not require susceptibility to HIV because of open sores their partner to use condoms or engage in or higher viral loads in secretions, as safe sexual practices because they are explained above. unaware of their partner's high-risk sexual According to the CDC, youth (ages 10-19) or drug-related behavior. and young adults (ages 20-24) are at higher risk for STDs than are other age groups. This increased risk may be due in part to multiple partners as well as to barriers to care and
District of Columbia Department of Health, The HIV/AIDS Epidemiologic Profile for the District of Columbia 18 (Dec. 2003).
20 HIV/AIDS IN THE NATION'S CAPITAL HPE :HIV/AIDS EPIDEMIOLOGY CHAPTER I:
Kompan Ngamsnga, Surveillance and Epidemiology Division, HIV/AIDS Administration, Data for Decision Making, Epidemiological Data 19, Presentation to the District of Columbia Ryan White Title I Planning Council (May 19, 2005).
prevention, including lack of insurance or MOTHER-TO-CHILD TRANSMISSION financing and lack of transportation.50 Only 1 percent of living AIDS cases in the SUBSTANCE USE AND ABUSE District has been attributed to mother-to-child transmission.54 However, between 1983 and Substance use and abuse is linked directly 2002, 95 percent of all children under the and indirectly to HIV transmission. HIV can age of 13 living with AIDS were infected with be transmitted directly through the sharing HIV through mother-to-child transmission. of drug paraphernalia including syringes. In Of these cases, about 60 percent were addition, drug and alcohol use can lead to diagnosed before the infant reached one risky sexual behavior. year of age.56 Injection drug use is a common mode of HIV transmission in the District. In 2002, 23 RISK BY POPULATION GROUP percent of the men living with AIDS and 40 IN THE DISTRICT percent of women living with AIDS reported exposure to HIV through injection drug use.51 PEOPLE OF COLOR Substance abuse is a significant concern in HIV/AIDS has disproportionately affected the District. In September 2003, a report by the African-American community. Nationally, the Mayor's Task Force on Substance Abuse African Americans have the highest rate Prevention estimated that approximately of new AIDS diagnoses among all ethnic 60,000 District residents were "addicted to groups. Locally, African Americans, who alcohol and other drugs."52 Nearly 10,000 represent nearly 60 percent of the District's District residents are estimated to be IDUs.53 population, account for 75 percent of the
DC APPLESEED CENTER 21 AIDS cases.57 Moreover, the rate of new women in particular represent the AIDS cases among African Americans has overwhelming majority of women with AIDS increased in recent years, even as the rate in the city, comprising 90 percent of women has decreased among other groups in the living with AIDS in the District.65 According to District.58 In addition, between 1990 and the most recently available data, women in 2002, 90 percent of the 13 to 19 year olds Ward 8 have the highest rate of living AIDS diagnosed with AIDS were African cases per 10,000.66 American.59 INCARCERATED INDIVIDUALS Latinos, who represent 8 percent of the population in the District,60 have the second In 2001, 1.9 percent of the prison population highest rate for new AIDS diagnoses both in the United States was estimated to be nationally and locally.61 Furthermore, when HIV-positive, almost five times the HIV compared to other ethnic groups, Latinos rate among the country's total population.67 are more likely to learn of their HIV-positive Inadequate data are available regarding status at a late stage of the disease, to delay the rate of HIV/AIDS among persons entry into care if HIV-positive, and to lack incarcerated in the District's correctional insurance to pay for care.62 The lack of facilities. linguistically and culturally-appropriate services and prevention messages tailored YOUTH to the Latino community exacerbate these In the District, there were 72 cumulative problems.63 cases of AIDS among youth ages 13 to 19 years old between 1990 and 2002.68 WOMEN Although the number of AIDS cases among HIV/AIDS among women of all ethnicities children and youth below the age of 19 has has been on the rise in recent years. Since remained constant over the past five years, 1993, the incidence of AIDS has been this may not reflect the trend of HIV increasing at a faster rate among women transmission in this group because HIV data than men in the District.64 African-American are not yet available in the District.69 One
District of Columbia Department of Health, The HIV/AIDS Epidemiologic Profile for the District of Columbia 31 (Dec. 2003).
22 HIV/AIDS IN THE NATION'S CAPITAL CHAPTER I: HIV/AIDS EPIDEMIOLOGY 23 33 (Dec. 2003). 72 As life expectancies life As 73 In addition, condom use among the 74 increase in general and those with HIV live medications, cases of longer due to available Although rise. AIDS among seniors may function tends to decrease with age, sexual erectile in treatment for recent advances lead to increased sexual may dysfunction the age of activity among individuals over 65. SENIOR CITIZENS on In the District, limited data are available the trend of HIV/AIDS incidence among seniors. Counseling and testing data indicate an the age of 60 constitute that people over increasing percentagediagnosed of all newly accounting for HIV cases in recent years, diagnosed HIV less than 1 percent of newly and 3.9 cases in 2000, 2.4 percent in 2001, percent in 2002. elderly may be less common because there elderly may is no risk of pregnancy. transgender District residents in 2000, the 25 percent was self-reported HIV prevalence male to female and 32 percent for overall transgender persons. The HIV/AIDS Epidemiologic Profile for the District of Columbia Undoubtedly, 70 District of Columbia Department of Health, According to a survey of 252 According 71 some members of that 20 to 24 year old some members of that 20 to 24 year 20. turned they before infected group were DC APPLESEED CENTER TRANSGENDER INDIVIDUALS on the information is veryThere little transgender population in the District. suggests that does exist What information HIV transgenders are at high risk for urban transgender When studied, infection. very to have been found populations have and rates nationwide, high HIV infection represent a population at significant risk HIV. for reason to believe that the AIDS incidence that the reason to believe olds underestimates the year to 19 among 13 rate of HIV transmission is the long lag true with HIV and the between infection a process that can AIDS, of development of new rate The years. take as long as 10 olds can give AIDS cases in 20 to 24 year rate some clues as to the HIV transmission people since these young among youth, contracted HIV in their teenage years. likely District counseling and testing Significantly, data from 2003 indicate that 20 to 24 year AIDS incidence that is three an olds have and a half times greater than the incidence olds. year to 19 among 13 CONCLUSION HIV may be transmitted through various means. In the District, the primary modes of transmission are sexual contact and injection drug use. In order to address the modes of transmission and the needs of different populations, the involvement and coordination of various agencies is required, as discussed in the next chapter.
ENDNOTES Gorbach, ed., 3d ed. 2003) [hereinafter "Prevention of HIV Transmission"]. 1 This general discussion relies heavily on the San Francisco AIDS Foundation, AIDS 101: Guide to HIV Basics (1998), available at 15 HIV Infection and AIDS, supra note 2. http://www.sfaf.org/aids101/ (last visited July 15, 2005) 16 Basic Facts about HIV/AIDS, supra note 12. [hereinafter "HIV Basics"]. 17 AIDS ACTION, What Works in HIV Prevention Among Substance 2 National Institute of Allergy and Infectious Diseases, HIV Infection Users 1 (2001), available at and AIDS: An Overview, (Mar. 2005), available at http://www.aidsaction.org/legislation/pdf/ww4su.pdf (last visited http://www.niaid.nih.gov/factsheets/hivinf.htm (last visited July July 15, 2005). 15, 2005) [hereinafter "HIV Infection and AIDS"]. 18 Prevention of HIV Transmission, supra note 14, at 1045-46. 3 Centers for Disease Control and Prevention, 1993 Revised Classification System for HIV Infection and Expanded Surveillance 19 Id. at 1046. Case Definition for AIDS Among Adolescents and Adults, 41 20 Id. MORBIDITY & MORTALITY WKLY. REP. RECOMMENDATIONS & REP. (Dec. 18, 1992), available at 21 HIV Infection and AIDS, supra note 2; INSTITUTE OF MEDICINE OF http://www.cdc.gov/mmwr/preview/mmwrhtml/00018871.htm (last THE NATIONAL ACADEMIES, REDUCING THE ODDS: PREVENTING visited July 15, 2005); see also HIV Infection and AIDS, supra PERINATAL TRANSMISSION OF HIV IN THE UNITED STATES 45 note 2. (Michael A. Stoto et al., eds., National Academy Press 1999), available at 4 See id. http://www.nap.edu/books/0309062861/html/index.html (last 5 Centers for Disease Control and Prevention, How Long Does it visited July 15, 2005). Take for HIV to Cause AIDS?, available at 22 Press Release, National Institutes of Health, Mother to Infant HIV http://www.cdc.gov/hiv/pubs/faq/faq4.htm (last visited Transmission Rate Less Than 2% in Phase III Perinatal Trial (Feb. 8, July 15, 2005). 2001), available at http://aidsinfo.nih.gov/aprs/ (last visited July 6 Id. 15, 2005); Hoosen Coovadia, Antiretroviral Agents – How Best to Protect Infants from HIV and Save Their Mothers from AIDS, 351 7 Id. NEW ENG. J. MED. 289-92 (July 15, 2004), available at 8 Id. http://content.nejm.org/content/vol351/issue3/index.shtml (last visited July 15, 2005). 9 HIV Infection and AIDS, supra note 2. 23 Jesse L. Goodman, The Safety and Availability of Blood and 10 Centers for Disease Control and Prevention, Incorporating HIV Tissues – Progress and Challenges, 351 NEW ENG. J. MED. 819-22 Prevention into the Medical Care of Persons Living with HIV, 52 ( Aug. 19, 2004), available at MORBIDITY & MORTALITY WKLY. REP. RECOMMENDATIONS & http://content.nejm.org/content/vol351/issue8/index.shtml (last REP. 9 (July 18, 2003), available at visited July 15, 2005). http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5212a1.htm (last visited July 15, 2005). 24 HIV Infection and AIDS, supra note 2. 11 Id. at 1-2. 25 Basic Facts about HIV/AIDS, supra note 12. 12 American Foundation for AIDS Research, Basic Facts about 26 Centers for Disease Control and Prevention, Basic Statistics (last HIV/AIDS, available at http://www.amfar.org/ revised June 20, 2005), available at cgi-bin/iowa/abouthiv/record.html?record=3 (last visited July 15, http://www.cdc.gov/hiv/stats.htm (last visited July 15, 2005). 2005). 27 Id. 13 Centers for Disease Control and Prevention, HIV Prevention through 28 Id. (citing M. Glynn and P. Rhodes, Estimated HIV Prevalence in the Early Detection and Treatment of Other Sexually Transmitted U.S. at the End of 2003, National HIV Prevention Conference (June Diseases - United States Recommendations of the Advisory 2005), Abstract 595). Committee for HIV and STD Prevention, 47 MORBIDITY AND MORTALITY WKLY. REP. RECOMMENDATIONS & REP. 1-24 (July 31, 29 Centers for Disease Control and Prevention, Cases of HIV Infection 1998), available at http://www.cdc.gov/nchstp/dstd/MMWRs/ and AIDS in the United States, 2003, 15 HIV/AIDS SURVEILLANCE HIV_Prevention_Through_Early_Detection.htm (last visited REPORT, (2004), available at July 25, 2005). http://www.cdc.gov/hiv/stats/2003SurveillanceReport.pdf (last visited July 18, 2005). 14 Jonathan Zenilman, Prevention of Human Immunodeficiency Virus Transmission, in INFECTIOUS DISEASES 1045 (Sherwood L.
24 HIV/AIDS IN THE NATION'S CAPITAL 30 Centers for Disease Control and Prevention, CDC Guidelines for administration_offices/apr/pdf/ National Human Immunodeficiency Virus Case Surveillance, part5_05_chapter2.pdf&group=1787&open=|33110|33120|33139| Including Monitoring for Human Immunodeficiency Virus Infection (last visited July 23, 2005) [hereinafter "D.C. Substance and Acquired Immunodeficiency Syndrome, MORBIDITY & Abuse Strategy"]. MORTALITY WKLY. REP. RECOMMENDATIONS & REP. 1 (Dec. 10, 53 HIV/AIDS Administration & HIV Prevention Community Planning 1999), available at http://www.cdc.gov/mmwr/PDF/rr/rr4813.pdf Group, District of Columbia HIV Prevention Two Year Plan 2003- (last visited July 18, 2005) [hereinafter "CDC Guidelines for 2004 2.8 (Sept. 2003), available at National HIV Case Surveillance"]. http://doh.dc.gov/doh/frames.asp?doc=/doh/lib/doh/services/ 31 HIV/AIDS Surveillance Report, supra note 29, at 27. administration_offices/hiv_aids/pdf/section2_needs.pdf (last visited July 23, 2005) [hereinafter "2003-2004 HIV 32 District of Columbia Department of Health, The HIV/AIDS Prevention Plan"]. Epidemiologic Profile for the District of Columbia 1 (Dec. 2003) [hereinafter "2003 Epi Profile"], available at 54 2003 Epi Profile, supra note 32, at 25. http://www.doh.dc.gov/doh/frames.asp?doc=/doh/lib/doh/ 55 Id. at 34. services/administration_offices/hiv_aids/pdf/epi_profile_2004.pdf (last visited July 23, 2005). 56 Id. 33 Id. 57 See id. at 22, 30. 34 District of Columbia Department of Health, The HIV/AIDS 58 Id. at 31. Epidemiologic Profile for the District of Columbia, December 2003: 59 Id. at 33. Supplemental Report 29 (Mar. 4, 2005), available at http://www.doh.dc.gov/doh/frames.asp?doc=/doh/lib/doh/ 60 Id. at 11. services/administration_offices/hiv_aids/pdf/EpiProfileSupplement 61 Id. at 31; Centers for Disease Control and Prevention, HIV/AIDS Final061505.pdf (last visited July 23, 2005) [hereinafter "2005 Epi Among Hispanics 1 (Nov. 2004), available at Supplement"]. http://www.cdc.gov/hiv/pubs/facts/hispanic.pdf (last visited 35 Id. July 15, 2005). 36 2003 Epi Profile, supra note 32, at 18. 62 National Alliance of State and Territorial AIDS Directors, Addressing HIV/AIDS...Latino Perspectives and Policy 37 See id.; National Institute of Allergy and Infectious Diseases, Recommendations 17 (July 23, 2003), available at Treatment of HIV Infection (2004), available at http://www.nastad.org/pdf/latinodoc.pdf (last visited http://www.niaid.nih.gov/factsheets/treat-hiv.htm (last visited July July 18, 2005). 19, 2005). 63 Id. at 25.
38 DC Appleseed Center et al., CareFirst: Meeting Its Charitable HIV/AIDS EPIDEMIOLOGY CHAPTER I: Obligation to Citizens of the National Capital Area III-3 (Dec. 6, 64 2003 Epi Profile, supra note 32, at 21, 25. 2004), available at 65 Id. at 21-22. http://www.dcappleseed.org/projects/publications/ 66 Id. at 36. DCA-Final-CareFirst-12-6-04.pdf (last visited July 25, 2005). 67 Laura M. Maruschak, HIV in Prisons, 2001, Bureau of Justice 39 2003 Epi Profile, supra note 32, at 25. Statistics Bulletin 2 (Jan. 2004), available at 40 Id. http://www.ojp.usdoj.gov/bjs/pub/pdf/hivp01.pdf (last visited July 41 Id. at 27. 18, 2005); Basic Statistics, supra note 26; U.S. Census Bureau, Table 1: Annual Estimates of the Population for the United States 42 Id. and States, and for Puerto Rico: April 1, 2000 to July 1, 2004 (Dec. 43 See Centers for Disease Control and Prevention, No Turning Back – 22, 2004), available at Addressing the HIV Crisis Among Men Who Have Sex with Men http://www.census.gov/popest/states/tables/NST-EST2004-01.pdf (Nov. 2001), available at (last visited July 25, 2005) [hereinafter "Annual http://www.thebody.com/cdc/msm/factor.html (last visited Population Estimates"]. July 18, 2005). 68 2003 Epi Profile, supra note 32, at 32-33. 44 See id. 69 Id. at 32. 45 2003 Epi Profile, supra note 32, at 21-22. 70 2005 Epi Supplement, supra note 34, at 34. 46 See AIDS ACTION, Policy Facts: Women and HIV/AIDS 1 (2002), 71 Id. available at http://www.aidsaction.org/legislation/pdf/PolicyFactsWomen.pdf 72 Whitman-Walker Clinic, HIV/AIDS and Transgender People 1 (Feb. (last visited July 18, 2005). See also Kaiser Family Foundation, Key 2005), available at http://www.wwc.org/PDF/factstransgender.pdf Facts: Women and HIV/AIDS 17 (2003), available at (last visited July 18, 2003). http://www.kff.org/hivaids/upload21820_1.pdf (last visited 73 2005 Epi Supplement, supra at 34, at 18. July 18, 2005). 74 See generally Constance G. Bacon et al., Sexual Function in Men 47 Press Release, Black Entertainment Television, Black Men and HIV: Older Than 50 Years of Age: Results from the Health Professionals Sexuality and Health Discussed at BET's Teen Summit (May 15, Follow-up Study, 139 ANNALS OF INTERNAL MED. 161-68 (Aug. 5, 2001), available at http://www.findwealth.com/ 2003), available at http://www.annals.org/cgi/reprint/139/3/161 black-men-amp-hiv-sexuality-261877pr.html (last visited (last visited July 18, 2005). July 23, 2005). 75 National Association of Social Workers, The Aging of HIV 2 (Apr. 48 2003 Epi Profile, supra note 32, at 39-44. 2003), available at http://www.naswdc.org/practice/hiv_aids/ 49 Id. AgingOfHIVFactSheet.pdf (last visited July 18, 2005). 50 Centers for Disease Control and Prevention, STDs in Adolescents and Young Adults (2002), available at http://www.cdc.gov/std/stats02/adol.htm (last visited July 18, 2005). 51 2003 Epi Profile, supra note 32, at 21-22. 52 Mayor's Interagency Task Force on Substance Abuse Prevention, Treatment & Control, First Citywide Comprehensive Substance Abuse Strategy for the District of Columbia 2-4 (Sept. 2003), available at http://doh.dc.gov/doh/frames.asp?doc=/doh/lib/doh/services/
DC APPLESEED CENTER 25
PART 1: CHAPTER II GOVERNMENT STRUCTURE
CHAPTER INFORMATION: THE FEDERAL GOVERNMENT THE DISTRICT OF COLUMBIA GOVERNMENT Department of Health HIV/AIDS Administration Other Relevant Offices within the DOH Other Relevant District Agencies Committees CONCLUSION
DC APPLESEED CENTER 27 This chapter presents an programs funded under the Ryan White Comprehensive AIDS Resources overview of the federal and Emergency Act (Ryan White). Ryan White provides funds to improve the quality District government agencies and availability of care for people with and programs that furnish HIV/AIDS and their families. prevention and care services z The Centers for Disease Control and Prevention (CDC) coordinates and leads for HIV/AIDS in the District. efforts in disease prevention and control, health promotion, and education. Through Several federal agencies provide its National Center for HIV, STD, and TB funding to the District for the Prevention, the CDC funds HIV/AIDS prevention grants, supplies local health provision of prevention and care departments with comprehensive HIV services for individuals with prevention programs, and coordinates and conducts surveillance on HIV/AIDS. HIV/AIDS. On a local level, HAA z The Substance Abuse and Mental has primary responsibility for Health Services Administration (SAMHSA), through its HIV/AIDS & addressing the HIV/AIDS Hepatitis Program Area, increases access epidemic. Although this report to prevention and treatment services for individuals with or at risk of HIV/AIDS does not recommend changing due to substance abuse and mental the District's government health disorders. SAMHSA places a particular emphasis on people of color structure for HIV/AIDS services, disproportionately affected by the subsequent chapters contain HIV/AIDS epidemic. z The Centers for Medicare & Medicaid recommendations for improving Services (CMS) works in partnership coordination among existing with the states to administer Medicaid. Nationally, Medicaid is the primary source agencies. of health insurance coverage for low- income beneficiaries living with HIV/AIDS.
z The Housing Opportunities for Persons with AIDS (HOPWA) office of the THE FEDERAL Department of Housing and Urban Development (HUD) provides housing GOVERNMENT assistance and related supportive services Several agencies within the federal for low-income persons with HIV/AIDS government play significant roles in providing and their families. HIV/AIDS care and prevention in the District. These federal agencies provide the vast majority of funding for local governments and service providers. They also conduct THE DISTRICT nation-wide epidemiological monitoring of public health, coordinate national prevention OF COLUMBIA and care efforts, and oversee how local governments use funds. GOVERNMENT The primary federal agencies addressing The DOH is responsible for coordinating HIV/AIDS are: health care services for the District's residents. Within the DOH, HAA focuses z The Health Resources and Services specifically on HIV; however, several other Administration (HRSA), through its DOH offices and District agencies play HIV/AIDS Bureau (HAB), administers all important roles in addressing the epidemic.
28 HIV/AIDS IN THE NATION'S CAPITAL DEPARTMENT OF HEALTH HIV/AIDS ADMINISTRATION The figure below shows the current structure HAA is responsible for funding and of the DOH, reflecting its reorganization in overseeing HIV/AIDS prevention and care late 2004. As a result of this reorganization, services for District residents. These services the Administrator of HAA now reports are provided primarily through partnerships directly to the Director of the DOH. with health and community-based HPE I GOVERNMENT STRUCTURE CHAPTER II:
Adapted from: Government of the District of Columbia, FY 2006 Proposed Budget and Financial Plan, available at http://www.dc.gov/mayor/budget_2006/agency_budget_chapters/pdf/hss_hc.pdf (last visited July 17, 2005).
DC APPLESEED CENTER 29 organizations. Services include medical the prevention of perinatal transmission support, HIV counseling and testing, of HIV. collection and analysis of data, and the provision of education, information, referrals, OTHER RELEVANT DISTRICT and intervention services. HAA's mission is AGENCIES to decrease the incidence of HIV/AIDS and the number of deaths related to HIV/AIDS Besides the DOH, other departments within in the District through surveillance, tracking, the District government provide services to monitoring, and intervention. at-risk populations: z The Department of Mental Health OTHER RELEVANT OFFICES WITHIN (DMH) coordinates the District's mental THE DOH health system and provides community As the agency responsible for coordinating mental health services and in-patient the District's response to HIV/AIDS, HAA services at St. Elizabeths Hospital. Many should have relationships with other offices individuals with mental illnesses are also within the DOH that serve populations with living with HIV/AIDS. a high incidence of HIV/AIDS: z The Department of Corrections (DOC) z The Addiction Prevention and Recovery houses a population with a high incidence Administration (APRA) focuses on the of HIV/AIDS. Through private contractors prevention and treatment of substance funded by HAA and the DOC, some abuse in the District. APRA provides inmates receive HIV prevention education, oversight, sets standards, and monitors testing and counseling, treatment, and the quality of substance abuse treatment discharge planning services. services delivered. APRA's Office of z District of Columbia Public Schools Special Population Services provides case (DCPS) is responsible for District youths' management, prevention education and education, including health education outreach, and specialized treatment related to HIV/AIDS. services for those living with HIV/AIDS.76 z The Income Maintenance z The Division of STD Control and Administration (IMA) administers the Prevention (STD Division) aims to curb District's welfare program, which provides the spread of STDs within the District, eligible District residents with services through clinical treatment services and such as cash assistance, Medicaid, and ongoing education and outreach with food stamps. Many HIV-positive individuals District residents and providers. The STD depend on these public programs. Division is responsible for providing STD z The Office of Gay, Lesbian, Bisexual, testing and treatment, counseling and and Transgender (GLBT) Affairs serves training, and surveillance of STD infection as a liaison to the Executive Office of the in the District. The Division also operates Mayor and other District agencies that the District's STD Clinic. provide services and community outreach z The Health Care Safety Net to GLBT constituents. The Office has Administration (HCSNA) oversees the established the Mayor's GLBT Executive Alliance, a partnership with private health Advisory Committee and sub-committees care providers in the District, to finance to define issues of concern to the GLBT health care for certain uninsured District community and find innovative ways of residents. utilizing government resources to help z The Medical Assistance Administration address pertinent issues. (MAA), the Medicaid agency for the District, administers health care financing COMMITTEES for eligible uninsured persons within the Both through federal mandate and local District. initiative, the District has established a z The Maternal and Child Health number of entities to address HIV/AIDS Administration addresses natal care and issues:
30 HIV/AIDS IN THE NATION'S CAPITAL z The Mayor's Advisory Committee target populations and interventions for on HIV/AIDS was created to advise each identified target population.78 This the Mayor, DOH, and HAA on the plan is developed from epidemiologic data development, implementation, and and an assessment of prevention needs. evaluation of HIV/AIDS policies in the z The Ryan White Planning Council, District. The Committee reviews existing as required by the federal government, and proposed HIV/AIDS policy, develops meets regularly to set funding priorities HIV/AIDS policy position papers, for allocating resources for the provision coordinates functions among other of HIV/AIDS services and to develop a advisory committees, and provides a forum plan for the organization and delivery of for District residents to voice concerns care services. The Planning Council is about existing and proposed HIV/AIDS comprised of representatives from a policy. It is composed of persons either number of groups affected by HIV/AIDS living with or affected by HIV/AIDS, as including, but not limited to: people living well as service providers, academics, with AIDS, the recently incarcerated, and government officials. women, MSM, and the organizations z The D.C. Council Committee on Health, that serve these populations. which was created in 2005, has jurisdiction over the DOH and health-related issues in the District. The committee is chaired by D.C. Councilmember David Catania and CONCLUSION includes Councilmembers Jack Evans, Several federal and District agencies are
Jim Graham, Vincent C. Gray, and Vincent GOVERNMENT STRUCTURE CHAPTER II: responsible for the provision of HIV/AIDS B. Orange, Sr.77 prevention and care services locally. Given z The HIV/AIDS Prevention Community the number of entities involved, strong Planning Group (CPG) is required for the coordination and leadership are essential, District to receive prevention funding from especially for the effective care of individuals the CDC. The District's CPG is comprised living with HIV/AIDS who may struggle with of affected populations, epidemiologists, multiple needs. Subsequent chapters contain scientists, providers, and public health specific recommendations for improving department staff. The CPG drafts a coordination among the relevant agencies. prevention plan that identifies priority
ENDNOTES 76 District of Columbia Department of Health, Substance Abusers At Risk or Living with HIV/AIDS, available at http://doh.dc.gov/doh/cwp/ view,a,1374,q,576040,dohNAV_G10,1803.asp (last visited July 17, 2005). 77 Council of the District of Columbia, Council Period 16 Committees, available at http://www.dccouncil.washington.dc.us/organization.html (last visited July 23, 2005). 78 Centers for Disease Control and Prevention, HIV Prevention Projects, Notice of Availability of Funds, 68 Fed. Reg. 41,138, 41,140 (July 10, 2003).
DC APPLESEED CENTER 31
PART 2 FINDINGS AND RECOMMENDATIONS CONCERNING THE DISTRICT'S RESPONSE TO THE HIV/AIDS EPIDEMIC
PART 2: CHAPTER III HIV AND AIDS SURVEILLANCE
CHAPTER INFORMATION: BACKGROUND HIV/AIDS Reporting Requirements – Education Goals and Purposes of and Enforcement Surveillance HIV Surveillance Data Storage and Protection Data Dissemination SUMMARY OF HIV/AIDS Reporting RECOMMENDATIONS Requirements CONCLUSION Data Storage and Protection FINDINGS AND RECOMMENDATIONS Leadership and Resources of the Surveillance and Epidemiology Division HIV Surveillance Data Dissemination
DC APPLESEED CENTER 35 HIV/AIDS surveillance is the reports of AIDS diagnoses. Surveillance tracks the spread of HIV infection and AIDS means by which government geographically, demographically, and by other categories such as risk factors – i.e., public health agencies track the characteristics or behaviors that place an impact of HIV and AIDS. Positive individual at high risk for HIV infection. The analysis of HIV and AIDS data is critical to HIV test results and AIDS understanding modes of transmission and diagnoses are aggregated and other characteristics of the HIV/AIDS epidemic. An understanding of the number analyzed to generate local and of individuals living with HIV/AIDS and national surveillance data. modes of HIV transmission allows for a better allocation of funding and more Surveillance data are then used appropriate planning of care and treatment to make determinations about services. In the District, HAA is responsible for how to allocate funding, both on conducting HIV and AIDS surveillance a local and federal level, and to through its Surveillance Division. Primarily funded by the CDC, Surveillance Division formulate effective treatment staff investigates potential HIV and AIDS cases and their modes of transmission, and prevention strategies. As analyze data, prepare epidemiologic will be discussed further below, statistical reports and data presentations, and respond to requests for information. the collection and analysis of Collaborating with other divisions within HIV infection data are critical to DOH, HAA, and community planning groups, the Surveillance Division prepares the assessing the current state of epidemiologic data reports required to receive federal funding for HIV prevention the epidemic and developing an and care programs. effective and targeted response. HIV SURVEILLANCE This chapter provides background information Since the 1980s, public health agencies on HIV and AIDS surveillance in the District. have been conducting AIDS surveillance It then explains the importance of to monitor the impact of the HIV/AIDS surveillance data and analysis, and identifies epidemic. According to the CDC, prior to current deficiencies in the District's system the advent of effective therapy for HIV/AIDS for collecting, analyzing, and effectively in 1996, AIDS surveillance data "reliably disseminating timely surveillance data. detected changing patterns of HIV This chapter then recommends steps for transmission and reflected the effect of ensuring adequate staffing of HAA's HIV prevention programs on the incidence Surveillance Division, increasing data of HIV infection and related illnesses in dissemination (including HIV data), enforcing specific populations."79 After 1996, however, existing HIV/AIDS reporting requirements, HIV/AIDS medication slowed the progression and improving data storage and protection. of HIV to AIDS, so that AIDS surveillance no longer reliably reflected trends in HIV transmission.80 AIDS surveillance, therefore, BACKGROUND could not accurately inform the need for prevention and care services because AIDS data fail to account for the significant number GOALS AND PURPOSES of people who have HIV but have not yet OF SURVEILLANCE developed AIDS.81 Hence, AIDS surveillance HIV/AIDS surveillance efforts involve the alone can no longer provide a complete aggregation of HIV testing results and picture of the epidemic.
36 HIV/AIDS IN THE NATION'S CAPITAL Following the development of antiretroviral surveillance.88 As part of their comprehensive therapy in 1996, the CDC recommended in HIV/AIDS surveillance programs, numerous 1997 that all public health agencies conduct states have been conducting HIV surveillance surveillance of HIV infections in addition to since 1985.89 AIDS surveillance.82 HIV surveillance has a HAA currently collects HIV case reports, number of important benefits compared to which include risk behavior information, so AIDS surveillance. First, HIV data provide that trends in mode of transmission can be a more complete reflection of the numbers identified among subpopulations.90 However, of people infected with the virus at the HAA has yet to release data concerning the present time than AIDS data alone. Second, District's HIV incidence and prevalence and HIV surveillance provides more current trends in mode of transmission among information regarding trends in modes of subpopulations. According to Dr. Matthew transmission within subpopulations than McKenna, Chief of HIV Incidence and that offered by AIDS surveillance. Surveillance at the CDC, the CDC does not The District has conducted AIDS surveillance have any standards regarding the maturation since the early stages of the epidemic. time for data in HIV surveillance systems Physicians and laboratories report AIDS using coded UIs.91 However, Dr. McKenna cases to DOH and identify each case by the says it takes about two years to have quality patient's name and address.83 In 1999, the data in any reporting system and four to five District began to develop a process for HIV years to have data that are useful for trend reporting. Although the District had been analysis.92 Supporting this position, the conducting name-based AIDS surveillance for Institute of Medicine of the National many years, some District residents opposed Academies reports, "Case reporting systems SURVEILLANCE AIDS HIV AND CHAPTER III: such surveillance. According to Marlene N. for new diseases take time to mature and Kelley, M.D., the Interim Director of DOH become fully operational. For a system at the time, the opposition was due to to operate well, physicians and other "historical experiences of discrimination and practitioners need to be educated about fear of losing confidentiality about one's HIV the need for new requirements for disease status."84 Dr. Kelley said that some people reporting. The burden of new reporting in the District believed that name-based obligations can be increased by complex surveillance would deter people in certain data requirements, such as the creation high-risk populations from getting tested of encryption codes for patients in states for HIV.85 with code-based reporting."93 Community debate concerning whether to conduct HIV surveillance by name or by DATA DISSEMINATION coded unique identifier (UI) lasted several HAA disseminates AIDS surveillance data years. District officials implemented HIV and analysis through data presentations, reporting by coded UI in January 2001, when fact sheets, responses to individual data HIV became a reportable disease in the requests, and the Epidemiologic Profile 86 District. The District's UI is a combination (Epi Profile). The Epi Profile is a required of letters and numbers derived from portions component of the HIV Prevention Plan, of the person's last name and social security which the District should submit to the number, as well as his or her date of birth CDC as part of its application for funding and sex. for HIV prevention activities. By the time HAA received the first HIV case The Epi Profile typically includes summaries reports in December 2001, many jurisdictions of AIDS incidence, prevalence, rates, and had already been collecting HIV infection trends. The Epi Profile presents AIDS data 87 case information for several years. In fact, by gender, race or ethnicity, age, mode of the CDC reported that as of November 1, transmission, and geographic area. Data on 1999 – approximately one year after CDC had AIDS and comorbidities, such as STDs, are issued guidance for HIV surveillance – 34 also provided. states had implemented HIV surveillance using name-based reporting, whereas four The Epi Profile is used to prepare the states were using a coded UI system for HIV District's Prevention Plan every other year. The CDC requires HAA and the HIV/AIDS
DC APPLESEED CENTER 37 Community Planning Group (CPG) to work barriers, electronic protections, and standard collaboratively to prepare the Prevention operational procedures such as limiting Plan in order to apply for CDC funding for access to authorized personnel, shredding prevention interventions, which are further of documents, password-protecting and discussed in Chapter IV. HAA is responsible encrypting data, and maintaining all HIV/AIDS for providing guidance to the CPG, surveillance reports and data in a physically developing the Epi Profile, and conducting secure location and confidential manner at all an assessment of services available in the times.101 Information security policies also community.94 The CDC's guidance indicates should incorporate provisions for the removal that the Epi Profile and the community of personally identifying information and services assessment should be discussed encryption before electronically transferring and agreed upon by both the health AIDS case data to the CDC.102 department and the CPG in order to facilitate the efficiency and effectiveness of the prevention planning process.95 The CPG reviews and uses key data (including the FINDINGS AND Epi Profile and the community services assessment) to establish priorities for RECOMMENDATIONS prevention activities in the community.96 The District's HIV/AIDS surveillance program needs significant improvements. Additional Epidemiologic Profile: staff is needed to investigate, collect, A document that describes the HIV/AIDS epidemic within various review, enter, manage, analyze, interpret, populations and identifies characteristics of both HIV-positive and and evaluate HIV/AIDS epidemiologic and HIV-negative persons in defined geographic areas. It is composed behavioral data. In addition, improved of information gathered to describe the effect of HIV/AIDS on an dissemination of surveillance data is critical. area in terms of sociodemographic, geographic, behavioral, and While the Surveillance Division provides clinical characteristics. The epidemiologic profile serves as the AIDS data and formula-based estimates scientific basis for the identification and prioritization of HIV of HIV incidence to the CPG and the Ryan White Planning Council, the Surveillance prevention and care needs in any given jurisdiction. Division has not disseminated the District's HIV surveillance data and has no immediate Centers for Disease Control and Prevention, HIV Prevention Community Planning Guide 20 (2003). plans to do so.
LEADERSHIP AND RESOURCES HIV/AIDS REPORTING OF THE SURVEILLANCE AND REQUIREMENTS EPIDEMIOLOGY DIVISION In the District, physicians and laboratories HAA's Surveillance Division has a significant are required by law to report a diagnosis of number of personnel vacancies and is HIV or AIDS to HAA within 48 hours of currently headed by its second consecutive diagnosis.97 These reporting requirements interim director.103 Of the Surveillance can be enforced through civil fines or Division's 10 staff members, there is only penalties.98 Furthermore, a physician licensed one staff assistant.104 As a result, the by the District may lose his or her license Surveillance Division has been unable to to practice medicine if he or she willfully provide timely input of data.105 The vacancy fails to make the required reports.99 rate of over 50 percent has had a significant impact on the Surveillance Division's ability DATA STORAGE AND to fulfill its objectives and on the morale PROTECTION of the Surveillance Division's staff.106 The CDC's Guidelines for HIV/AIDS There are currently 13 vacant positions in Surveillance call for protections and security the Surveillance Division, many of which measures to uphold the integrity and have been vacant for over one year.107 The confidentiality of the surveillance system, District has received federal funding for information, and records.100 These these positions; thus, there would be requirements include the use of physical minimal, if any, costs to the District to fill
38 HIV/AIDS IN THE NATION'S CAPITAL these positions. Despite the available D.C. Council Committee on Health, HAA funding, it appears that insufficient effort officials stated that to ensure the inclusion of currently is invested in advertising and filling prevalent HIV cases and unbiased data, HIV these vacancies.108 For example, eight of data should not be released until the agency these positions were not posted on the has accumulated five years of data.117 Based District's Office of Personnel website until on surveillance best practices, it takes about May 2005, and it does not appear that two years for an HIV surveillance program the other five positions have ever been to gather mature data and two or three more advertised.109 HAA staff reports that they years before trends in the data can be made a request to the CDC in early fall of interpreted.118 Mature data may be released 2004 for seven CDC staff to be detailed to with appropriate caveats, even before trend the Surveillance Division.110 HAA staff also analysis can be completed.119 HAA should reports, however, that they are unaware therefore disseminate the District's HIV data of the CDC ever providing a large number with the necessary caveats in order to of full-time staff to a local public health provide information about HIV transmission agency,111 and thus it seems unlikely that during particular time periods. If vacancies CDC will provide the necessary staff. The in the Surveillance Division are filled, HAA failure to fill these positions prevents the should have sufficient staffing resources Surveillance Division from performing its to disseminate HIV data promptly. duties and results in the District's need to In order for HAA to be able to conduct trend 112 reprogram federal funds. The DOH and analysis of the District's HIV data, the HIV HAA Directors should make the leadership data must be complete. HAA's Counseling, and staffing of the Surveillance Division a Testing, and Referral (CTR) program data on SURVEILLANCE AIDS HIV AND CHAPTER III: top priority. individuals tested for HIV at publicly-funded The vacancies in the Surveillance Division sites or events can be used to gain insight were raised in a recent hearing before the on HIV prevalence and incidence. But these D.C. Council's Committee on Health.113 At data are for a limited cross-section of the the hearing, HAA indicated that the hiring District's population and cannot be used process and bureaucracy at HAA, DOH, to determine the District's HIV prevalence and the Office of Personnel had impeded and incidence. For HAA's HIV data to be attempts to fill these vacancies.114 In order complete and representative of the District's to facilitate the hiring of new staff, Chairman population, the CTR data must be David Catania offered to introduce an supplemented by HIV case reports from emergency measure granting HAA private medical offices and laboratories. HAA temporary hiring authority to bypass the should therefore ensure that physicians and Office of Personnel and attempt to fill the laboratories report all HIV cases in a timely positions on its own.115 In a CPG meeting on manner, as further discussed below. July 22, 2005, HAA staff reported that direct In addition, HAA needs to complete an hiring authority would be welcomed and that evaluation of its HIV surveillance system HAA is currently discussing the possibility prior to publishing information on trends in 116 with the Deputy Mayor's office. It is critical HIV data. HAA reports that it is not equipped that the staffing vacancies in the Surveillance to conduct the necessary in-depth process of Division are filled, and HAA should pursue evaluating the proficiency of its UI code, the every possible means of addressing its efficiency of the UI database system, and personnel shortages. the timeliness of case reporting. The UI system needs evaluation for several reasons, HIV SURVEILLANCE including the large number of duplicate or Accurate and complete HIV surveillance incomplete HIV case reports. HAA staff data are essential to plan HIV prevention reports that for every 26 HIV case reports, programs and allocate healthcare resources. there is only one new unduplicated and Although HAA has collected HIV data for the complete HIV case. Given the understaffing past three and a half years, it has not yet of the Epidemiology and Surveillance publicly disseminated a report on HIV data. Division, HAA should contract with an During a recent public hearing before the outside expert to evaluate the HIV surveillance system. HAA may be able to
DC APPLESEED CENTER 39 obtain additional funding from the CDC to failure to provide necessary epidemiological hire this outside expert. In the alternative, data and other information, the Plan was not HAA should explore the possibility of ready as of July 2005.122 In a June 29, 2005 partnering with a local university or research letter to the CDC, the CPG requested the organization to conduct the evaluation at a CDC's assistance in moving the prevention reduced rate or on a volunteer basis. planning process forward.123 HAA staff indicates that the release of HIV It is critical that the Prevention Plan be based data may be further delayed if the District on accurate and complete epidemiological changes its UI. Specifically, legislation data and that the CPG receives all required pending before the D.C. Council would documents from HAA. That is not now the amend the District's HIV reporting case. Epidemiological data provide the requirements by prohibiting the use of social primary basis for the development of the security numbers and country of origin as Prevention Plan. The Prevention Plan plays a part of the HIV case report.120 The CDC's significant role in the CDC's determination Dr. McKenna confirms that, based on the of the District's prevention funding levels. experience of other jurisdictions, altering Given the importance of the Prevention Plan, the District's UI would likely be a significant the Surveillance Division should devote setback in terms of the ability of the necessary resources to preparing the Epi Surveillance Division to analyze and Profile and responding to data requests from disseminate HIV data promptly.121 the CPG. Various CPG members have The central problem remains that current publicly stated that collaboration between staff vacancies preclude HAA from HAA and the CPG generally, and between completing the necessary collection, the Surveillance Division and the CPG in analysis, evaluation, and dissemination of particular, has been lacking. In part, the HIV data. District decision makers should ineffective collaboration may stem from the realize that until these staffing resources overextended and understaffed Surveillance are provided, it is unlikely that critical HIV Division. In order to provide effective and surveillance data will be disseminated. timely support to the CPG's prevention planning process, HAA must obtain sufficient staffing in the Surveillance Division and DATA DISSEMINATION should make an institutional commitment to Data dissemination is indispensable for improved communication and collaboration the optimal allocation of prevention and both within the agency and with the CPG. care services. For example, the District's In order to strengthen the prevention CPG relies on the Epi Profile to prioritize planning process in the District, HAA and the prevention activities in the District. During CPG should also consult with the Behavioral the community planning process for the and Social Science Volunteer Program (BSSV) 2005-2006 CDC-mandated Prevention Plan, of the American Psychological Association, the CPG experienced difficulty obtaining Office on AIDS. The BSSV, a national HIV the necessary epidemiologic data. prevention technical assistance program The 2003 Epi Profile was distributed in funded by the CDC, has a network of December 2003. In April 2004, the CPG behavioral and social science volunteers to communicated its concerns about offer free and ongoing technical assistance to deficiencies in the 2003 Epi Profile to HAA. assist with HIV prevention planning efforts.124 HAA, in consultation with CPG members, In addition to the CPG, the Ryan White produced a Supplemental Report to the 2003 Planning Council relies on the Epi Profile, which was approved by the vote epidemiological data compiled by HAA in of a quorum of CPG members in April 2005. order to allocate federal funding for HIV/AIDS HAA's failure to present comprehensive services. Like the CPG, the Ryan White data to the CPG in a timely manner Planning Council has experienced difficulties contributed to the delay in the development in obtaining data from HAA. of the 2005-2006 HIV Prevention Plan. The HAA should publicly disseminate data 2005-2006 HIV Prevention Plan was due in in more frequent reports. The only December 2004; however, due to HAA's epidemiological information on HAA's
40 HIV/AIDS IN THE NATION'S CAPITAL website is the 2003 Epi Profile and the survey indicated that at least one doctor did related 2005 supplement. In addition to the not understand the reporting regulations and required Epi Profile, HAA should disseminate that some were concerned both about the other data on a regular basis. Cities including time required to make these reports as well New York, San Francisco, and Baltimore as patient privacy.131 In a related study to publish quarterly reports on HIV and/or AIDS assess the completeness of the HIV/AIDS surveillance data on their websites.125 case reports submitted by seven private Some county and state health departments, doctors between 1996 and 1998, HAA including those of Illinois, California, concluded that private doctors significantly Massachusetts, and Seattle/King County, underreport HIV/AIDS diagnoses.132 Although provide monthly surveillance reports on their the study was based on a small sample, websites.126 The CDC recommends regular HAA officials have pointed to the results as publication of such data for the use of health evidence that HIV/AIDS cases may be agencies, community planning groups, underreported. The extent to which data are academia, providers, and the public.127 In being incompletely or inaccurately reported addition, Philadelphia, Baltimore, New York, is unknown, but other jurisdictions, including San Francisco, and Los Angeles make California, have identified serious problems de-identified, unanalyzed HIV and AIDS data with underreporting and reporting delays by publicly available for independent analysis. private physicians.133 An additional study will In sum, to ensure access to accurate and be necessary to provide an accurate picture timely information on the local HIV/AIDS of underreporting by private doctors; the epidemic, HAA should publish surveillance study should also include reporting by
data and reports regularly on its website. laboratories to fully capture the reporting SURVEILLANCE AIDS HIV AND CHAPTER III: Additional recommendations about the situation in the District. HAA should consider content of HAA's website are discussed seeking additional funding to complete the in Appendix C. reporting study. There are inexpensive methods that could HIV/AIDS REPORTING be utilized to heighten physicians' REQUIREMENTS – EDUCATION understanding of the importance of the AND ENFORCEMENT reporting regulations and improve their compliance with those regulations. When HAA officials expressed concern about the the HIV reporting requirement became timeliness and completeness of HIV/AIDS effective in 2001, HAA conducted a multi- case reporting by doctors and laboratories.128 pronged campaign to publicize the new HAA officials cite discrepancies in reported reporting requirement to both the general data versus the data that are discovered public and the medical community. Among when the Surveillance Division staff visits other efforts, HAA created a website, private doctors' offices to survey medical http://www.hivcounts.net, to provide records, a process called "active information about the HIV/AIDS reporting surveillance." The CDC recommends that, regulations, including the forms for the to ensure that all data are accurate and required case reports. Such efforts should be complete, active surveillance should be done strengthened and conducted on an ongoing routinely in addition to passive surveillance basis. For example, the D.C. Board of (the receipt of HIV/AIDS case report from Medicine, which is responsible for regulating doctors' offices and laboratories).129 doctors practicing in the District, maintains a Furthermore, CDC guidelines advise that website134 and periodically publishes a all surveillance programs should conduct newsletter for District-licensed physicians.135 regular, ongoing assessments of their Both the website and newsletter should be surveillance and reporting systems.130 used to publicize the importance of the To date, HAA has undertaken only one small reporting requirements. Similarly, the Medical study to assess the reporting by private Society of the District of Columbia, a private physicians. Several years ago, to assess organization, maintains a website and private doctors' understanding of and publishes a monthly newsletter for its compliance with the reporting requirements, physician members.136 The Medical Society HAA conducted a survey of 11 doctors. The publishes on its website reporting
DC APPLESEED CENTER 41 requirements related to other STDs.137 assistance from a local university, another HAA could request that HIV/AIDS reporting organization, or the CDC to integrate the HIV requirements also be published on the and AIDS databases. Medical Society website and, at virtually Another problem with HAA's databases is no cost, communicate these reporting that HAA does not maintain secure back-up requirements to the several thousand files of surveillance data.138 In the event of members of the Medical Society. HAA a fire, flooding, or other disaster at HAA’s should undertake this and other simple and headquarters, the surveillance data could be inexpensive methods of communication. lost. HAA would then be at risk for losing Although HAA attributes its data problems funding, and both HAA and the District's at least in part to physician and laboratory CBOs would be unable to plan their priorities noncompliance with reporting requirements, and activities based on up-to-date, accurate no enforcement action has ever been information. The current back-up is brought against a physician or laboratory. To insufficient in that: (1) the back-up relies on the extent that HAA identifies unreported data from the District's regular reports to cases, enforcement action should be taken. CDC, which do not include all data elements It is likely that consistent enforcement of the collected, and (2) the data collected between law would increase the timely reporting by submission of reports to the CDC would be private medical offices and laboratories. In lost. HAA should ensure that all of its data order to enforce the reporting requirements, are regularly backed up at a remote secure HAA staff should notify the DOH General location. Off-site storage is considered to Counsel of any suspected violations. After an be the best practice in the medical investigation, the DOH General Counsel may community.139 For example, the California refer substantiated violations to the Attorney Health & Safety Code mandates that all General for enforcement action. The DOH medical records stored on an electronic General Counsel's office reports that it has medium must also have an off-site back-up not been informed of any violations. HAA storage system.140 If the District uses should not simply accept failures by doctors storage space in an existing District office and laboratories to report HIV and AIDS building, the cost associated with off-site cases without referring such failures to the data back-up should be minimal. Attorney General for enforcement action. To the extent that the referral mechanism is perceived as cumbersome or ineffective, legislative action may be necessary to SUMMARY OF enable HAA or DOH staff to warn and fine physicians and laboratories in order to RECOMMENDATIONS ensure prompt and complete reporting. Leadership and Staffing Resources. DOH and HAA should move quickly to DATA STORAGE AND ensure adequate staffing of the Surveillance PROTECTION Division and utilize existing CDC funding fully by filling the 13 vacant positions in the HAA uses separate databases for HIV and Surveillance Division. If hiring qualified AIDS data, which creates unnecessary work. personnel cannot be achieved quickly, For each new HIV or AIDS case report, staff HAA should explore mechanisms such as must check each database for possible contracting with outside entities to staff duplicate records. If a case report includes critical surveillance functions. As a priority, both an HIV and an AIDS diagnosis, the data HAA should make every effort to hire must be entered twice. Furthermore, two immediately a qualified, experienced databases complicate data analysis. For epidemiologist with proven management these reasons, HAA should combine HIV ability and familiarity with HIV/AIDS and AIDS data into a single database, with surveillance to head this critical department. the assistance of qualified information technology consultants. As with the HIV Data Analysis and HIV/AIDS Data evaluation of the HIV surveillance system, Dissemination. To enhance and direct HAA should explore the possibility of seeking District planning and policy making, HAA
42 HIV/AIDS IN THE NATION'S CAPITAL should make HIV data available immediately reporting and ensure accountability, HAA with appropriate caveats. HAA should also should conduct an in-depth study of reporting contract with an expert to evaluate the HIV by private doctors and laboratories. surveillance system. Both HIV and AIDS Data Storage and Protection. HAA should data should be analyzed and reported on a combine its HIV and AIDS databases into quarterly basis. In preparing the quarterly a single database system, and should take reports, HAA should present data in a user- steps to ensure that surveillance data are friendly format. Both reports and data sets backed up at a remote data storage site. should be made available on the HAA website. HAA should also evaluate its processes for supporting the planning roles of the CPG and the Ryan White Planning Council and develop a workable method CONCLUSION for providing timely, accurate epidemiologic Remedying current deficiencies in the data to both groups. In addition, HAA analysis and dissemination of surveillance should make available de-identified data data should be a priority in the District. sets to enhance transparency and facilitate These data significantly impact the outside analysis of the data. Additional deployment of prevention efforts and the recommendations about the content of allocation of adequate care resources for HAA's website are discussed in Appendix C. persons living with HIV/AIDS. Leadership and staffing should be improved in order to HIV/AIDS Reporting Requirements. The ensure the proper analysis and dissemination District, through the Attorney General,
of data. In addition, coordination with SURVEILLANCE AIDS HIV AND CHAPTER III: should enforce existing HIV/AIDS reporting responsible enforcement agencies will requirements by levying fines on physicians improve accountability of providers and labs and laboratories that fail to report cases of and ensure collection of relevant data. HIV or AIDS. To improve compliance, HAA should renew its efforts to publicize the HIV/AIDS reporting requirements to private doctors, other providers, and laboratories. The Board of Medicine and the Medical Society of the District of Columbia each appear to offer effective vehicles to promote compliance at little cost. In order to evaluate
ENDNOTES 88 Id. 79 CDC Guidelines for National HIV Case Surveillance, supra note 30, 89 Id. at 3. 90 Interview with District of Columbia government officials. 80 Id. 91 Telephone Interview with Dr. Matthew T. McKenna, Chief, HIV 81 Id. Incidence and Surveillance Branch, Division of HIV/AIDS Prevention, National Center for HIV, STD, and TB Prevention, 82 Id. Centers for Disease Control and Prevention (July 1, 2005) 83 22 D.C. Mun. Regs. §§ 206.2-.3 (2005). [hereinafter "July 1 Telephone Interview with Dr. Matthew T. 84 Letter from Marlene N. Kelley, Interim Director, District of Columbia McKenna"]. Department of Health, to Phil Mendelson, Councilmember (At 92 Id. Large), Council of the District of Columbia (Apr. 12, 1999), 93 INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES, available at MEASURING WHAT MATTERS: ALLOCATION, PLANNING, AND http://www.glaa.org/archive/1999/nameskelley0412.shtml#kelley QUALITY ASSESSMENT FOR THE RYAN WHITE CARE ACT 91 (last visited July 22, 2005). (2004). 85 Id. 94 Centers for Disease Control and Prevention, HIV Prevention 86 22 D.C. Mun. Regs. §§ 206 (2005). Community Planning Guide 15-16 (2003), available at 87 CDC Guidelines for National HIV Case Surveillance, supra note 30, http://www.cdc.gov/hiv/PUBS/hiv-cp.pdf (last visited July 22, 2005) at 3. [hereinafter "HIV Prevention Community Planning Guide"].
DC APPLESEED CENTER 43 95 Id. at 16. 124 American Psychological Association, Behavioral and Social Science Volunteer Program, available at 96 Id. at 17. http://www.apa.org/pi/aids/bssv.html (last visited July 23, 2005). 97 22 D.C. Mun. Regs. §§ 201.5; 206.2; 211.4 (2005). 125 See generally The New York City Department of Health and Mental 98 Id. at § 200.4. Hygiene, HIV Epidemiology Program, available at 99 D.C. Code Ann. § 3-1205.14(a)(9) (2004). http://www.nyc.gov/html/doh/html/dires/dires.shtml (last visited July 23, 2005); San Francisco Department of Public Health, AIDS 100 CDC Guidelines for National HIV Case Surveillance, supra note 30, Surveillance Unit, available at at 15. http://www.sfdph.org/PHP/AIDSSurvUnit.htm (last visited July 23, 101 Id. 2005); Maryland Department of Health and Mental Hygiene, Statistics, available at http://dhmh.state.md.us/AIDS/epictr.htm 102 Id. (last visited July 23, 2005). 103 Interview with District of Columbia government official. 126 See generally Illinois Department of Public Health, HIV/AIDS 104 Id. Statistics, available at http://www.idph.state.il.us/aids/stats.htm 105 Id. (last visited July 23, 2005); California Department of Health Services Office of AIDS, HIV/AIDS Epidemiology, available at 106 Id. http://www.dhs.ca.gov/ps/ooa/Statistics/default.htm (last visited 107 Id. July 23, 2005); Commonwealth of Massachusetts Department of Public Health, HIV/AIDS Surveillance Program, available at 108 Interviews with District of Columbia government officials. http://www.mass.gov/dph/cdc/aids/aidsprog.htm (last visited July 109 HIV/AIDS Administration, Oversight Questions and Answers, 23, 2005); Public Health-Seattle/King County, HIV/AIDS Program, Attachment Q1: Personnel Actions, D.C. Council Committee on available at http://www.metrokc.gov/health/apu/epi/index.htm Health Oversight Hearing on the HIV/AIDS Administration (June (last visited July 23, 2005). 23, 2005). 127 CDC Guidelines for National HIV Case Surveillance, supra note 30. 110 Testimony of Lydia Watts, Director, HIV/AIDS Administration, D.C. 128 Testimony of Gail Maureen Hansen, Interim Director, Surveillance Council Committee on Health Oversight Hearing on the HIV/AIDS and Epidemiology Division, HIV/AIDS Administration, D.C. Council Administration (June 23, 2005). Committee on Health Oversight Hearing on the HIV/AIDS 111 Id. Administration (Mar. 17, 2005). 112 Testimony of Lydia Watts, Director, HIV/AIDS Administration, and 129 CDC Guidelines for National HIV Case Surveillance, supra note 30. Remarks of David Catania, Chairman, D.C. Council Committee on 130 Id. Health, D.C. Council Committee on Health Oversight Hearing on the HIV/AIDS Administration (June 23, 2005). 131 Mekbeb Teferra & Joan Wright-Andoh, District of Columbia Department of Health, Survey Questionnaire Conducted to Selected 113 Remarks of David Catania, Chairman, D.C. Council Committee on Private Medical Doctors that Participated in the Study of Health, D.C. Council Committee on Health Oversight Hearing on the Completeness of HIV/AIDS Reporting in D.C. (1996-1998). HIV/AIDS Administration (June 23, 2005). 132 Mekbeb Teferra & Joan Wright-Andoh, District of Columbia 114 Testimony of Lydia Watts, supra note 110. Department of Health, Completeness of AIDS Case Reporting from 115 Remarks of David Catania, supra note 113. Private Medical Doctors in D.C. (1996-1998). 116 Remarks of Ronald King, Interim Director, Prevention Division, 133 Charles Ornstein, Report System on HIV Cases Falters, L.A. TIMES, HIV/AIDS Administration, HIV Prevention Community Planning Jan. 11, 2003, at B1. Group Meeting (July 22, 2005). 134 District of Columbia Department of Health, Board of Medicine, 117 Testimony of Gail Maureen Hansen, Interim Director, Surveillance available at http://doh.dc.gov/doh/cwp/ and Epidemiology Division, HIV/AIDS Administration, and Ivan view,a,1371,q,600687,dohNav_GID,1881,dohNav,|34373|34382|.asp Torres, Former Interim Director, HIV/AIDS Administration, D.C. (last visited July 23, 2005). Council Committee on Health Oversight Hearing on the HIV/AIDS 135 District of Columbia Department of Health, Professional Licensing Administration (Mar. 17, 2005). Board Newsletters, available at http://doh.dc.gov/doh/cwp/ 118 July 1 Telephone Interview with Dr. Matthew T. McKenna, supra view,a,1371,q,600330,dohNav_GID,1881,dohNav,|34373|34382|.asp note 91. (last visited July 23, 2005). 119 Telephone Interview with Dr. Matthew T. McKenna, Chief, HIV 136 Medical Society of the District of Columbia, available at Incidence and Surveillance Branch, Div. of HIV/AIDS Prevention, http://www.msdc.org (last visited July 23, 2005). National Center for HIV, STD, and TB Prevention, Centers for 137 Medical Society of the District of Columbia, Member Center: Disease Control and Prevention (July 14, 2005) [hereinafter "July Sexually Transmitted Diseases (Reporting Them in DC), available at 14 Telephone Interview with Dr. Matthew T. McKenna"]. http://www.msdc.org/memberCenter/ 120 HIV Unique Identifier System Amendment Act of 2005 (B16-0116) § SexuallyTransmittedDiseasesReportingtheminDC.shtml (last 2, Council of the District of Columbia (2005), available at visited July 25, 2005). http://www.dccouncil.washington.dc.us/images/00001/ 138 Interview with District of Columbia government official. 20050211094055.pdf (last visited July 23, 2005). 139 Robert Lowes, Backing-up Data is Forward-thinking, 80 MED. 121 July 14 Telephone Interview with Dr. Matthew T. McKenna, supra ECON. 15 (Oct. 24, 2003). note 119. 140 Cal. Health & Safety Code § 123149 (2005). 122 Interview with District of Columbia government official. 123 Letter from District of Columbia HIV Prevention Community Planning Group to William Longdon, Project Officer, CDC (June 29, 2005).
44 HIV/AIDS IN THE NATION'S CAPITAL PART 2: CHAPTER IV FUNDING AND GRANT MANAGEMENT
CHAPTER INFORMATION: BACKGROUND Quality Assurance Grant Monitoring Overview of Funding Program Outcome Monitoring Quality Assurance HIV Prevention Funding Quality of Care Program Outcome Monitoring HIV/AIDS Health Care and FINDINGS AND Quality of Care Treatment Funding RECOMMENDATIONS SUMMARY OF Medicaid Funding RECOMMENDATIONS Section 1915(c) Waiver Single Point of Entry CONCLUSION Section 1115 Demonstration The District's AIDS Drug Project Assistance Program Ticket to Work Demonstration Maximizing Medicaid Enrollment D.C. Healthcare Alliance Medicaid Reimbursement for Ryan White CARE Act HIV/AIDS Services Grant Management Grant Management Grant Award Process Grant Payment Process Grant Monitoring Grant Awards and Renewals
DC APPLESEED CENTER 45 In addition to conducting HIV patients who lack insurance. Medicare (which is available to the elderly and and AIDS surveillance, the disabled) and private insurance also provide government funds, coordinates, reimbursement to CBOs. The District appropriates its own local funds and oversees CBOs that furnish to match certain federal health care coverage HIV/AIDS prevention and care programs and fully funds the Alliance. In addition, local appropriations may be used services in the District. This to fund services independently of federal funding. In fiscal year 2005, the District chapter discusses the funding appropriated over $9 million for personnel and shortcomings of HIV/AIDS costs and services for HIV/AIDS.141 services and the management SAMHSA and HUD also provide funding for specialized services to those living with of government grants to CBOs. HIV/AIDS. SAMHSA provides funding for substance abuse prevention and treatment. It then makes specific HUD established the Office of HIV/AIDS recommendations for developing Housing, which manages the Housing Opportunities for Persons with AIDS a centralized application process (HOPWA) program that funds programs for the District's public benefit addressing the specific housing needs of persons living with AIDS.142 programs, expanding the For fiscal year 2005, HAA's budget is prescription drugs covered by $80,912,903, 89 percent of which is from 143 certain publicly-funded programs, federal sources. In addition to government-administered maximizing enrollment in funds, private entities provide limited funding for HIV/AIDS-related services. Medicaid, increasing Medicaid Private foundations and other non-profit reimbursement for HIV/AIDS organizations play an important role in supporting HIV/AIDS service providers, services, improving HAA's particularly to fill gaps when there are grant management process, restrictions on the use of public funds. and creating accountability HIV PREVENTION FUNDING mechanisms to improve the CDC prevention grants are the major source quality of services provided of prevention funds for many jurisdictions, including the District. In order to receive a to District residents. CDC grant, a jurisdiction must develop a comprehensive HIV prevention plan with the input of its HIV Prevention Community Planning Group (CPG); the development of BACKGROUND this plan ensures community participation in the identification of funding priorities. OVERVIEW OF FUNDING Prevention planning must be evidence-based and incorporate views and perspectives of HIV/AIDS prevention and care services are groups at risk for HIV, as well as providers of funded primarily through public sources. CDC HIV prevention services.144 The overall goal and HRSA provide federal funds for HIV/AIDS of a CPG is to identify the populations at services through grants to HAA, which in high risk and in greatest need of prevention turn provides subgrants to CBOs. Medicaid services, and to develop a prevention plan and the Alliance reimburse CBOs and other to guide the allocation of needed prevention health care providers for covered health care resources. services furnished to eligible low-income
46 HIV/AIDS IN THE NATION'S CAPITAL HPE V FUNDING AND GRANT MANAGEMENT CHAPTER IV: HIV/AIDS Administration Fiscal Year 2005 Budget, Presented by Sumita Chaudhuri, Administrative Services Manager, HIV/AIDS Administration, to the Mayor's HIV/AIDS Advisory Committee Meeting (Oct. 13, 2004).
To implement the HIV Prevention Plan MEDICAID funded by the CDC's grant, the District Medicaid is the joint federal-state health contracts with CBOs. The District's CDC insurance program for certain low-income prevention grant for 2005 totals $5,988,005. individuals. Medicaid serves as an important The CDC grant funds prevention services source of health care coverage for persons including counseling and testing, individual with HIV/AIDS, both in the District and and group health education and risk- nationwide. The District's Medicaid program reduction programs, logistical support for the currently covers over 140,000 beneficiaries.145 CPG, capacity building and training, and In fiscal year 2001, 3,499 Medicaid evaluation services. HAA is currently funding beneficiaries in the District were estimated 13 subgrants for health education and risk- to be living with HIV/AIDS.146 The District's reduction interventions. The CDC also funds Medicaid program is administered by the certain District-based CBOs directly on a MAA, within the District's DOH. Eligibility competitive basis. for Medicaid is determined by the IMA, which is within the District's Department HIV/AIDS HEALTH CARE AND of Human Services. TREATMENT FUNDING Because the District receives 70 cents from There are three principal funding sources the federal government for every dollar the in the District to pay for HIV/AIDS care and District spends on Medicaid, the District has treatment services for the uninsured: a strong incentive to maximize enrollment Medicaid (for low-income persons who meet in Medicaid, rather than in programs funded the eligibility requirements); the Alliance (for solely with local resources. However, low-income persons who do not meet the because federal matching funds are available Medicaid eligibility requirements); and the only for certain categories of beneficiaries, Ryan White CARE Act (which serves as a the District must craft any attempted payor of last resort for certain HIV/AIDS expansion of its Medicaid program carefully. services for individuals for whom no other The District's Medicaid eligibility source of funds is available). requirements and benefits are discussed in detail in Appendix D. Of the publicly-funded
DC APPLESEED CENTER 47 health care programs available to persons SECTION 1115 DEMONSTRATION PROJECT with HIV/AIDS in the District, Medicaid Section 1115 demonstrations allow states offers the best combination of services for to test policy ideas, such as providing care beneficiaries, cost-effectiveness for the for a limited time period to additional District, and long-term financial stability. populations that otherwise would not be States can expand their Medicaid coverage eligible for Medicaid. The District's Section and services by amending their state 1115 demonstration is intended to "provide Medicaid plans or using Medicaid waivers more effective, early treatment of HIV and demonstration programs. Medicaid disease by making available all Medicaid waivers allow states to receive federal services, including antiretroviral therapies."149 matching funds for covering additional The Section 1115 demonstration was categories of beneficiaries or services that implemented on January 14, 2005,150 four are not ordinarily eligible for matching funds. years after the Secretary of HHS approved Demonstration programs are short-term the District's application for the project. tests of whether additional beneficiaries District officials attribute the lengthy delay or services can be covered without in the implementation of the Section 1115 increasing the Medicaid program's costs to demonstration to numerous logistical the federal government. Both waivers and difficulties, including the establishment of a demonstration projects require approval from network of pharmacies for beneficiaries.151 CMS, part of the U.S. Department of Health During the five-year Section 1115 and Human Services (HHS), and are demonstration, up to 620 HIV-positive evaluated by CMS at their completion. The persons with incomes at or below 100 District currently has one waiver and two percent of federal poverty level (FPL) and demonstration programs targeting persons resources within the categorically-needy with HIV/AIDS, described below. limits will be allowed to enroll in Medicaid.152 The program aims to offset the costs of this SECTION 1915(C) WAIVER coverage expansion with the savings The District currently has a Home and achieved from purchasing antiretrovirals for Community-Based Services waiver under all HIV-positive Medicaid beneficiaries at Section 1915(c) of the Social Security Act the discounted prices uniquely available exclusively for the benefit of persons with to the District. HIV/AIDS. Section 1915(c) allows states to As of March 17, 2005, all Medicaid waive Medicaid's usual requirements beneficiaries were required to fill their regarding financial eligibility, comparability prescriptions for antiretrovirals at the 24 of services, and statewide availability of participating Care Pharmacy Network stores. services in order to provide home and HAA uses a single application to determine a community-based services. By waiving beneficiary's eligibility for the Section 1115 these requirements, states can use more demonstration program, as well as both the liberal income and resource requirements Ticket to Work demonstration and the District for persons needing home and community- ADAP program, which are described below. based services. All waivers must be approved by HHS, are subject to the state's TICKET TO WORK DEMONSTRATION usual federal match, and must be budget neutral. Specifically, the per capita expenses The District's most successful program to of services provided under the waiver must expand Medicaid coverage to persons not exceed the costs of hospital, nursing with HIV/AIDS is its "Ticket to Work" home, or institutional care that would be demonstration project. The Ticket to Work provided if the waiver were not in place.147 and Work Incentive Improvement Act of 1999 allows states to use demonstration projects The District's Section 1915(c) waiver, to provide Medicaid benefits and services implemented in 2000, provides water to help working individuals control the filters to individuals with HIV/AIDS whose progression of health conditions that may compromised immune systems may be lead to disability. The District's Ticket to Work harmed by contaminants in the water demonstration, one of only two such 148 system. HIV-specific demonstration programs in the
48 HIV/AIDS IN THE NATION'S CAPITAL nation, expands Medicaid eligibility to include RYAN WHITE CARE ACT persons with HIV who (1) work at least 40 The Ryan White Comprehensive AIDS hours per month; (2) have incomes under Resources Emergency Act of 1990 (Ryan 300 percent of FPL; and (3) do not have White)158 is an important source of federal job-related health insurance. The District funds for health care services for District program's enrollment is capped at 420 residents with HIV/AIDS. Ryan White persons; HAA has filled the program and services are intended to reduce costly currently has a waiting list of 75 persons. inpatient care, increase access to care for underserved populations, and improve the D.C. HEALTHCARE ALLIANCE quality of life for those affected by the Many of the District's low-income residents epidemic. Ryan White funds local and state who do not qualify for Medicaid, including programs that provide primary medical care single, childless adults, can receive health and support services, health care provider services through the Alliance. The Alliance training, and technical assistance to help is a public-private partnership funded by the funded programs address implementation District government for residents who lack and emerging HIV/AIDS care issues. health insurance and whose income is at or Ryan White funding159 is administered at the below 200 percent of the FPL. The Alliance's federal level by HRSA. Ryan White functions providers include four area hospitals and as a payor of last resort for those individuals numerous primary care and specialty who cannot cover the costs of their care and physicians. As of October 2003, 22,650
for whom no other source of payment for FUNDING AND GRANT MANAGEMENT CHAPTER IV: individuals were enrolled in the Alliance services, public or private, is available.160 The program.154 District received over $15 million in Ryan The purpose of the Alliance, created in 2001, White funding in fiscal year 2005.161 Ryan is "to shift medical care from an emergency White funds are administered based on the room and acute care setting to community- funding priorities established by the Ryan based health clinics and primary care White Planning Council, described in Chapter physicians."155 Many District residents II above. historically relied on emergency rooms as the primary care provider for their health The CARE Act is scheduled for Congressional reauthorization care services. The Alliance aims to change in 2005. AIDS advocates expect Congress to consider several this practice by providing a network of changes to Ryan White programs, including new methods of primary care locations throughout the city, allocating funds, requirements for services to be provided, and including private non-profit clinics, federally definitions of communities that are eligible to receive funding. qualified health centers and hospital-affiliated The services and funding options described in this report could clinics.156 The eligibility requirements and be affected by these changes. benefits of the Alliance are discussed in Appendix D. In addition to creating the Alliance, the Ryan White provides funding for the AIDS District has undertaken a major effort to Drug Assistance Program (ADAP). ADAP is improve access to primary care in the city. administered by states using a combination The Medical Homes Project, funded by local of state and federal funds.162 The program and federal grants, is a 10-year project to provides access to HIV/AIDS prescription expand the District's network of primary care drugs for low-income people who are clinics and providers and ensure a "medical uninsured, unable to obtain adequate home" for all District residents. A medical prescription drug coverage through a private home is defined as "a primary care provider insurer, and are ineligible for Medicaid and where a patient's health history is known, Medicare. For many impoverished people, where a patient is seen regardless of ability ADAP is the only source of HIV-related to pay and where a patient routinely seeks medications.163 States determine which medical care."157 drugs to include on the program formulary and programs vary in medical and financial eligibility requirements.
DC APPLESEED CENTER 49 HAA operates the District ADAP164 program financial audits by the jurisdiction or a primarily using federal funding; the District's third party.169 contribution is only 3 percent of the total ADAP budget. The District also benefits from QUALITY ASSURANCE access to discounted drug prices, which are unavailable to state ADAPs.165 PROGRAM OUTCOME MONITORING Program outcome monitoring typically GRANT MANAGEMENT entails before-and-after assessments of To properly administer the multiple funding interventions with individuals and groups to streams for HIV/AIDS services in the District, determine the extent to which the particular HAA must have a functioning grants intervention achieved changes in expected management system in place. Grantees behavior. This differs from formal outcome should be paid in a timely manner and grant evaluation, in which the particular renewals should be expeditiously processed. intervention is isolated to determine a causal Furthermore, appropriate monitoring of relationship between the intervention and grantee compliance with grant award terms changes in behavior.170 However, the CDC must exist. In addition, HAA should conduct has compiled a list of evidence-based regular program outcome monitoring of interventions, and requires public health grantees to ensure that the program is agencies to fund only those interventions effectively reaching its objectives. For that have been proven effective, so that grantees providing care services to clients formal outcome evaluation is not with HIV/AIDS, a quality assurance system necessary.171 Program outcome monitoring should be instituted to ensure quality care. is necessary to ensure that that the funded program's objectives for its target population GRANT AWARD PROCESS are being met. HAA distributes funding, both federal and QUALITY OF CARE local, through grants to dozens of organizations that provide HIV/AIDS care and Given the complexity of health issues treatment and prevention services. In the associated with HIV/AIDS, which will be case of federally-funded grants, HAA applies discussed in Chapter VI, it is critical that for funding and receives a notice of grant persons with HIV/AIDS receive quality care award from the federal grantor. After placing services. Quality assurance programs can a notice of funding availability in the D.C. ensure that providers give adequate Register, HAA releases a request for HIV/AIDS care, which can prevent patients application. An external review panel scores from developing serious and costly health applications submitted by CBOs, and HAA complications. Any quality assurance then convenes an internal review panel to program must begin with the development review the external scoring and proposals. of relevant standards.172 After HAA reaches final decisions on grant awards, it requires that grantees sign agreements setting out the terms of the award before commencing the provision FINDINGS AND of services.166 RECOMMENDATIONS GRANT MONITORING Jurisdictions receiving federal grants must FUNDING monitor the compliance of subgrantees with both program and fiscal requirements.167 SINGLE POINT OF ENTRY Subgrantees must meet the performance The first challenge facing an individual with goals listed in the grant, and they must HIV/AIDS seeking medical benefits is the employ fiscal controls to ensure use of enrollment process. Currently, many of the awards for the authorized purpose.168 Some District's various publicly-funded health monitoring mechanisms include: progress care programs use separate enrollment reports, site visits, financial reports, and procedures. The Section 1115 demonstration,
50 HIV/AIDS IN THE NATION'S CAPITAL the Ticket to Work demonstration, and entry" system. In this system, an individual ADAP share a single four-page application, attempting to access benefits at a provider which is processed by HAA. Enrollment site or through HAA must first apply for in Medicaid outside the HIV/AIDS ADAP benefits.176 The ADAP office then demonstrations, however, requires a different enters the application data into a database six-page application, processed by the IMA. system called XPRES.177 The XPRES system The Alliance uses a third application, which screens the application data for eligibility in is collected at participating clinics and the various public benefit programs, including processed by a contractor. District officials Medicaid and the Alliance.178 If eligible for report that IMA will process a single ADAP, the applicant is enrolled in ADAP application for Medicaid and the Alliance by HAA.179 If the applicant is eligible for starting in spring 2006.173 Medicaid or the Alliance, the individual is Multiple enrollment requirements may referred to IMA or the Alliance to complete 180 confuse beneficiaries and discourage them the appropriate application process. Once from completing the paperwork necessary the applications for Medicaid and the Alliance to receive their benefits. Although individuals are combined, HAA will presumably provide may not qualify for the first program to a single referral to IMA for enrollment in which they apply, they could qualify for both programs. another program. All of the District's public A true single point of entry is a system in benefits programs should coordinate which one application is processed by one enrollment procedures and referrals to help agency to determine eligibility and benefits HPE V FUNDING AND GRANT MANAGEMENT CHAPTER IV: direct beneficiaries to the correct programs. for every publicly-funded health care Although combining the Alliance and program. In contrast, HAA's current model Medicaid applications is a good first step, facilitates only limited access and referrals to more can be done. Since the District intends other programs. Often, an individual applicant to integrate the enrollment process for must still complete multiple applications. these two programs, only a limited amount A true single point of entry would require of additional funding would be necessary additional integration and coordination to implement a true single point of entry between providers, HAA, IMA, and the system. Alliance to ensure that the applicant receives Complicated and uncoordinated enrollment the necessary benefits through a single processes not only diminish the chance that application. For example, the application for eligible recipients will be served, they also these health coverage services should be cost the District significant amounts of processed through a single database system. money. Although the Alliance is supposed With such a system, there would need to to verify that an applicant is not eligible for be appropriate protections to ensure that Medicaid before enrolling the beneficiary, each agency only has access to the data some patients who are eligible for Medicaid necessary for its program and staff using have nevertheless been enrolled in the the system would need to receive Alliance, at great cost to the District. For confidentiality training. example, in 2001, MAA reported that 1,382 Alliance patients were also enrolled in THE DISTRICT'S AIDS DRUG Medicaid.174 The OIG determined that the ASSISTANCE PROGRAM District would have needlessly spent over The District ADAP eligibility requirements are $284,000 if this enrollment error had not among the most generous in the nation.181 been discovered.175 District officials report Residents with incomes up to 400 percent of that MAA compares Medicaid enrollment the FPL ($38,280 for a single person in 2005) with Alliance enrollment every two weeks to are eligible to enroll in the District ADAP, and minimize duplicate enrollment. The District like most states, the District ADAP requires should continue to ensure that Medicaid- only documentation from a physician eligible residents are enrolled in Medicaid, confirming an individual's HIV-positive status not the Alliance. or a copy of the positive HIV test result.182 In contrast, some states' financial eligibility Recognizing these challenges, the DOH has thresholds are set as low as 200 percent of attempted to develop its own "single point of FPL. Other states, including Arkansas,
DC APPLESEED CENTER 51 Georgia, and Virginia, require that the reimbursement system in 1989 that has applicant establish that he or she meets significantly increased Medicaid certain CD4 cell count or viral load reimbursement for HIV/AIDS services.190 requirements prior to enrollment in the For example, Medicaid reimbursement for program.183 By not requiring individuals intermediate level office visits for patients to meet a prescribed CD4 cell count or with HIV/AIDS was raised to $276 from viral load, the District ADAP assures that $67.50.191 MAA should explore the every HIV-positive District resident who implementation of a similar system of is financially eligible may enroll in the augmented Medicaid reimbursement for program.184 The District ADAP also has District HIV/AIDS services. no waiting list for access to the program and no enrollment caps or per capita GRANT MANAGEMENT spending limits are planned or in place.185 The accessibility of the District's ADAP GRANT PAYMENT PROCESS program is commendable. Most CBOs depend on timely receipt of Some consumers have criticized the grant funding from government agencies District's ADAP formulary. The formulary to support the uninterrupted provision of currently covers 67 prescription drugs. The services. Unfortunately, HAA's slow grant formulary includes HIV/AIDS treatments, approvals and renewals, delayed payments, including all of the approved antiretrovirals, and burdensome audit requirements make it as well as other medicines that treat difficult for many of these organizations to opportunistic infections.186 Consumers in fulfill their obligations under their subgrants. focus group meetings organized by DC Delays in grant payments make it difficult Appleseed reported that D.C.'s ADAP does for organizations to provide care while also not cover a sufficient number and variety of meeting their rent and payroll obligations.192 drugs to treat opportunistic infections and Many of the District's HIV/AIDS service other conditions. D.C.'s ADAP formulary providers are small, non-profit groups that includes 47 such drugs, while the are heavily reliant on their subgrants from Connecticut ADAP formulary includes 138 HAA and do not have the resources to drugs.187 If sufficient funding is available, remain open for months without payment. consideration should be given to expanding The D.C. Council Committee on Health held D.C.'s ADAP formulary. hearings on May 18 and 25, 2005 to address MAXIMIZING MEDICAID ENROLLMENT longstanding, pervasive payment delays that jeopardize the provision of HIV/AIDS care The OIG issued a report in June 2005 noting and other services to District residents. that the failure of three subgrantees to Representatives from numerous CBOs obtain Medicaid certification "resulted in the testified that HAA reimbursements for grant District losing the opportunity to receive expenditures are consistently late and often $1.1 million in federal reimbursements from several months past due. At the May 25 188 Medicaid." HAA should ensure that all hearing, DOH Director Gregg Pane and HAA subcontractors that provide Medicaid- Administrator Lydia Watts committed to covered services be certified Medicaid streamlining the grant payment process and providers. This would ensure that Ryan ensuring payment within a 20- to 30-day White funds are not used to provide services period from the submission of necessary that could be reimbursed by the Medicaid documentation.193 At a follow-up hearing on program. June 23, 2005, reports from HAA and CBOs suggested that improvements had been MEDICAID REIMBURSEMENT FOR made to the payment system. HIV/AIDS SERVICES The hearings demonstrate how focused Providers report that the District's Medicaid public attention and commitment of reimbursement rates are extremely low. Executive Branch resources can spur agency Medicaid pays between $35 and $90 per action. Both the Council and the Mayor's office visit, while the cost per visit is office should require that HAA meet the estimated to be $135 to $150.189 By accelerated payment schedule and continue contrast, New York instituted a multi-tiered
52 HIV/AIDS IN THE NATION'S CAPITAL to publicly address these and other vital controls at HAA.203 DOH's response to the issues related to HIV/AIDS care and services. OIG report contains specific steps for instituting internal controls to ensure that GRANT AWARDS AND RENEWALS current grant monitoring policies will be Various providers have reported that HAA followed.204 DOH should move quickly to is slow in processing grant announcements adopt necessary internal controls and the and renewals, even for longstanding OIG's recommendations. subgrantees.194 HAA's delays in processing grant renewals can jeopardize access to care. QUALITY ASSURANCE HAA should process grant renewals in a timely manner to ensure that CBOs can PROGRAM OUTCOME MONITORING provide continuous services to individuals In addition to monitoring existing grant living with HIV/AIDS. requirements, HAA should establish and implement comprehensive program outcome GRANT MONITORING monitoring requirements to evaluate whether In addition to payment delays, testimony by funded prevention and care programs are HAA, the OIG, and several subcontractors at effectively meeting District needs. For a March 17 hearing revealed that HAA's grant example, HAA should require CBOs to monitoring procedures often are not followed conduct pre- and post-intervention tests and result in payment to subcontractors for in order to assess the impact of prevention services they may not have provided.195 The
interventions. FUNDING AND GRANT MANAGEMENT CHAPTER IV: OIG's final report indicates that HAA kept HAA staff has reported that program inadequate and inaccurate records of site monitoring has been difficult due to poor visits and failed to perform many required data collection.205 However, to improve visits.196 HAA's grant monitoring policy collection of data regarding prevention requires at least four site visits per year to interventions from CBOs and comply with each grantee.197 HAA grant monitors a CDC mandate, HAA recently implemented reported that they typically conduct only two the CDC's Program Evaluation and site visits per year due to time constraints.198 Monitoring System (PEMS) on June 10, Yet, the OIG audits also indicate that HAA's 2005.206 10 grant monitors, each of whom has an average caseload of nine subgrantees, are in HAA officials note that monitoring and fact sufficient to complete the four requisite continued training for providers regarding the site visits per year.199 regular collection and input of accurate data into this database will be a challenge.207 The auditors found significant problems Nevertheless, HAA should use data collected beyond the failure to perform site visits. through PEMS to assess program outcomes There was no evidence of HIV/AIDS services and work with CBOs to develop strategic being provided at two grant sites, and some plans for improving services. grant monitors did not know the current locations of some subgrantees they were QUALITY OF CARE responsible for monitoring.200 In addition, the OIG found that HAA grant monitors did not In order to ensure that all people living with discover until the conclusion of the grant HIV/AIDS receive the quality of care they award that several subgrantees fell short of need, it is necessary for all implicated meeting their targets for delivering services agencies to increase accountability and as described in their grant agreements.201 oversight and to impose outcome measures The OIG also determined that 19 providers on the programs they administer. HAA were unauthorized to provide services in the recently began the process of developing District either because their incorporation more outcome measures and standardization documents had been revoked or because across its service areas due to last year's they did not have the required business mandate by HRSA to implement a "Quality licenses.202 The OIG suggests that Management Plan." In cooperation with the inadequate grant monitoring is the result Ryan White Planning Council, HAA staff has of insufficient training and supervision of developed quality assurance standards HAA grant monitors and a lack of internal that are included in grant agreements;
DC APPLESEED CENTER 53 compliance with the standards is subject to periodic evaluation.208 In 2003 and 2004, SUMMARY OF HAA staff reviewed the medical records of 20 providers for a number of quality RECOMMENDATIONS assurance indicators for primary care, case Single Point of Entry Enrollment. The management, mental health, and substance District should develop a centralized abuse.209 DC Appleseed did not evaluate application process, to be administered by the appropriateness of HAA's quality IMA, for enrollment and eligibility verification assurance standards or the adequacy of for Medicaid, the Alliance, Ticket to Work, the provider reviews. ADAP, and other programs. Once basic standards have been developed, Expand ADAP Formulary. If sufficient several options exist for implementing quality funding is available, the District should assurance. For example, recognizing that consider expanding the ADAP formulary to limited staff resources can challenge provider include a greater number of drugs to treat ability to evaluate and measure services, the opportunistic infections and other conditions. HIV/AIDS Planning Council staff in Seattle Maximize Medicaid Enrollment. The includes an Assessment Coordinator that District should use funding sources more agencies are encouraged to use as a efficiently by maximizing enrollment technical assistance resource. The District in Medicaid. Providers should ensure that could also utilize incentives to ensure patients are enrolled in the Medicaid adherence to developed standards. Some program if they are eligible. Furthermore, incentive programs, including several now the District should develop specific protocols being tested by Medicare,210 offer providers for verifying Medicaid eligibility and ensuring additional payments for reporting data on that all subcontractors that provide their performance on specific quality Medicaid-covered services are certified measurements. Others reward providers Medicaid providers. who meet standards with bonus payments Increase Medicaid Reimbursement. The or penalize providers who fail to meet the District should explore the possibility standards by reducing their reimbursement. of increasing Medicaid reimbursement for There currently is a great deal of interest HIV/AIDS services. on the part of health policy experts in such "pay-for-performance" approaches.211 Grants Management. HAA should ensure prompt payment of grants and should The District Medicaid and Alliance programs evaluate the newly developed payment could be used to collect data on the quality process for timeliness. Furthermore, HAA of care and outcomes for persons living with should ensure grant renewals are HIV/AIDS. For example, the District could expeditiously processed. HAA should also propose a Medicaid demonstration program promptly adopt internal controls to ensure to offer additional payments to providers who adequate grant monitoring as recommended report data on critical health care measures by the OIG. for persons with HIV/AIDS, such as adherence to drug regimens, and control of Quality Assurance. HAA should implement diabetes, heart disease, and opportunistic a comprehensive system of program infections, and patient education. These data outcome monitoring, utilizing the data would help the District monitor the quality of collected through PEMS to assess the care provided and could lead to the effectiveness of funded prevention development of quality-based payment interventions. In addition, relevant payors, systems. Once the District has data on the including Medicaid and the Alliance, should quality of care currently provided, it could consider linking payment for care to implement a second phase of the measurable performance standards. demonstration whereby providers would be Furthermore, the District should explore a given higher reimbursement for meeting possible Medicaid demonstration program certain predefined quality standards. The that would involve "pay for performance" District should explore with CMS, providers, incentives for higher quality HIV/AIDS care. and standard-setting organizations whether such a program is feasible.
54 HIV/AIDS IN THE NATION'S CAPITAL CONCLUSION Improving services for people with HIV/AIDS in the District requires the most efficient use of funding. DOH should maximize the use of existing funds by ensuring that individuals are enrolled in the appropriate health coverage programs. CBOs must be paid sufficiently and in a timely manner to secure the stable provision of services. In addition, HAA should develop more effective accountability mechanisms to ensure effective prevention and quality care services.
ENDNOTES 154 DC Primary Care Association, Primary Care Safety Net: Health Care FUNDING AND GRANT MANAGEMENT CHAPTER IV: Services for the Medically Vulnerable in the District of Columbia 8 141 HIV/AIDS Administration Fiscal Year 2005 Budget, provided by (Oct. 2003), available at District of Columbia government official. http://www.dcpca.org/docs/10.03Primary_Care_Safety_Net.PDF 142 U.S. Department of Housing and Urban Development, HIV/AIDS (last visited July 15, 2005) [hereinafter "Primary Care Safety Net"]. Housing (2005), available at 155 District of Columbia Health Care Safety Net Administration, 2002 http://www.hud.gov/offices/cpd/aidshousing/index.cfm (last Annual Report v-2, available at visited July 23, 2005). http://doh.dc.gov/doh/frames.asp?doc=/doh/lib/doh/about/pdf/exe 143 Sumita Chaudhuri, Administrative Services Manager, HIV/AIDS cutive_summary.pdf&group=1802&open=|33200| (last visited July Administration, HIV/AIDS Administration Fiscal Year 2005 Budget, 23, 2005). Presentation to the Mayor's HIV/AIDS Advisory Committee 156 See id. Meeting (Oct. 13, 2004). 157 D.C. Primary Care Association, Medical Homes DC, available at 144 2003-2004 HIV Prevention Plan, supra note 53, at 1.2. http://www.dcpca.org/?template=medical_homes.html (last visited 145 District of Columbia Medical Assistance Administration, Medical July 15, 2005). Assistance Enrollment Report (May 2005). 158 Ryan White Comprehensive AIDS Resources Emergency Act of 146 The Lewin Group and Positive Outcomes, Inc., Summary of Key 1990, 42 U.S.C. §§ 300ff-300ff-111 (2003). Findings: Medicaid Databook on HIV-Infected Recipients 1 (Nov. 26, 159 Information on Ryan White derived from the National Alliance of 2002). State and Territorial AIDS Directors, Federal Funding Primer, 147 Social Security Act § 1915(c), 42 U.S.C. § 1396n (2005). available at http://www.nastad.org/pdf/FundingPrimer.pdf (last 148 Letter from Charlene Brown, Regional Administrator, Centers for visited July 15, 2005). Medicare & Medicaid Services, to Herbert H. Weldon, Jr., District 160 The Henry J. Kaiser Family Foundation, HIV/AIDS Policy Issue of Columbia Department of Health, available at Brief – Financing HIV/AIDS Care: A Quilt with Many Holes 12 (May http://www.cms.hhs.gov/medicaid/1915c/dc0317renltr.pdf (last 2004), available at http://www.kff.org/hivaids/upload/Financing- visited July 25, 2005). HIV-AIDS-Care-A-Quilt-with-Many-Holes.pdf (last visited July 15, 149 Centers for Medicare & Medicaid Services, District of Columbia 2005) [hereinafter "Financing HIV/AIDS Care"]. HIV/AIDS § 1115 Demonstration Fact Sheet, available at 161 Interviews with District of Columbia government officials. http://www.cms.hhs.gov/medicaid/1115/dchiv1115.pdf (last 162 Id.; HIV/AIDS Bureau, Health Resources and Services visited July 15, 2005). Administration, U.S. Department of Health and Human Services, 150 Tanya Ehrmann, HIV/AIDS Administration, The Care Pharmacy ADAP Fact Sheet (2004), available at Network and Medicaid Expansion Program, Presentation to HIV http://hab.hrsa.gov/programs/factsheets/adap1.htm (last visited Prevention Community Planning Group Meeting (Jan. 13, 2005); July 15, 2005). see also Press Release, National Public Health Information 163 The Henry J. Kaiser Family Foundation, AIDS Drug Assistance Coalition, Department of Health Rolls Out New Medicaid Program Fact Sheet (Apr. 2003), available at Expansion Program (Jan. 14, 2005), http://www.kff.org/hivaids/1584-04-index.cfm (last visited http://www.nphic.org/news/release_detail.asp?id=70 (last visited July 25, 2005). July 15, 2005). 164 M. Danielle Davis et al., National ADAP Monitoring Project Annual 151 Interview with District of Columbia government official. Report, Executive Summary 11-12 (May 2004), available at 152 Department of Health Rolls Out New Medicaid Expansion Program, http://www.kff.org/hivaids/loader.cfm?url=/commonspot/security/ supra note 150. getfile.cfm&PageID=36193 (last visited July 23, 2005) [hereinafter 153 HIV/AIDS Administration, District of Columbia Department of "National ADAP Annual Report"]. Health, Quarterly Progress Report for the Demonstration to 165 HIV/AIDS Administration, District of Columbia Department of Maintain Independence and Employment Grant (No. P-11-91421/3) Health, 2004 Grant Application for the Ryan White Comprehensive (Oct. 7, 2004); Eric M. Weiss, Council Balks at Mayor's Spending AIDS Resources Emergency (CARE) Act: Title II HIV Emergency Request, WASH. POST, Feb. 9, 2005, at B5. Relief Grant Program 125-26 (Feb. 2004); HIV/AIDS Bureau, Health
DC APPLESEED CENTER 55 Resources and Services Administration, U.S. Department of Health 189 D.C. Primary Care Association, Where We Are, Where We Need To and Human Services, ADAP Cost-Containment Strategies (July Go: The Primary Care Safety Net in the District of Columbia, 2005 2004), available at ftp://ftp.hrsa.gov/hab/adapcost.pdf (last visited Update, 5, 54 (2005), available at July 25, 2005). http://www.dcpca.org/docs/Pages_from_2005_Update_final.pdf (last visited July 18, 2005). 166 District of Columbia Department of Health, HIV AIDS Administration Granting Process, available at 190 Infectious Diseases Society of America, New York's Enhanced Fee- http://doh.dc.gov/doh/frames.asp?doc=/doh/lib/doh/services/ for-Services Rate Program: A Model for Financing Medicaid HIV administration_offices/hiv_aids/pdf/grant_architecture.pdf Care (May 2004), available at (last visited July 23, 2005). http://www.idsociety.org/Template.cfm?Section=Home&CONTENTI D=9698&TEMPLATE=/ContentManagement/ContentDisplay.cfm 167 Office of Inspector General, U.S. Department of Health and Human (last visited July 23, 2005). Services, Protocol for Assessing States' Monitoring of Subgrantees 2-3 (OEI-05-03-00062) (Dec. 2004), available at 191 Id. http://oig.hhs.gov/oei/reports/oei-05-03-00062.pdf (last visited 192 E.g., Testimony of Ron Mealy, Executive Director, Carl Vogel Center, July 23, 2005). D.C. Council Committee on Health Oversight Hearing on the 168 Office of Management and Budget, Audits of State, Local HIV/AIDS Administration (May 18, 2005). Governments, and Non-Profit Organizations and OMB Circular A- 193 Testimony of Gregg Pane, Director, District of Columbia Department 133, 62 Fed. Reg. 35,278, 35,297 (June 30, 1997) (amended June of Health, and Lydia Watts, Administrator, HIV/AIDS 27, 2003 in 68 Fed. Reg. 38,401), available at Administration, D.C. Council Committee on Health Oversight http://www.whitehouse.gov/omb/circulars/a133/a133.html Hearing on the HIV/AIDS Administration (May 25, 2005). (last visited July 23, 2005). 194 Testimony of Catalina Sol, Director, HIV/AIDS Department, La 169 Protocol for Assessing States' Monitoring of Subgrantees, supra Clinica del Pueblo, and Dr. Patricia Hawkins, Associate Executive note 167, at 2. Director, Policy and External Affairs, Whitman-Walker Clinic, D.C. 170 Centers for Disease Control and Prevention, Evaluation Guidance Council Committee on Health Oversight Hearing on the HIV/AIDS Handbook: Strategies for Implementing the Evaluation Guidance for Administration (Mar. 3, 2005). CDC-funded HIV Prevention Programs 2 (Mar. 2002), available at 195 Testimony of William Divello, Assistant Inspector General for http://www.cdc.gov/hiv/aboutdhap/perb/guidance/chapter2.htm Audits, D.C. Council Committee on Health Oversight Hearing on (last visited July 23, 2005). the HIV/AIDS Administration (Mar. 17, 2005). 171 Interview with District of Columbia government official. 196 OIG Audit of HAA, supra note 188, at 5. 172 See, e.g., National Quality Measures Clearinghouse, Inclusion 197 Id. at 5. Criteria, available at http://www.qualitymeasures.ahrq.gov/about/inclusion.aspx 198 Id. (last visited July 15, 2005). 199 Id. at 7. 173 Interview with District of Columbia government officials. 200 Id. at 7-8. 174 Testimony of Charles C. Maddox, Esq., Inspector General, D.C. 201 Id. at 9-10. Council Committee on Human Services Hearing on Health Care Safety Net, 7-8 (Oct. 7, 2002), available at 202 Id. at 14-17. http://www.dcwatch.com/govern/ig021007.htm (last visited 203 Id. at 9. July 23, 2005). 204 Id. at 42-45. 175 Id. 205 Interview with District of Columbia government official. 176 Tanya Ehrmann, HIV/AIDS Administration, Presentation on the Care 206 Id. Pharmacy Network and Medicaid Expansion Program: New Programs for People Living with HIV/AIDS 32. 207 Id. 177 Id. 208 Id. 178 Id. 209 Brenda Clark, HIV/AIDS Administration, Quality Assessment and Outcome Measures, Presentation to the Ryan White Planning 179 Id. Council (May 19, 2005). 180 Id. 210 See, e.g., Centers for Medicare & Medicaid Services, Premier 181 National ADAP Annual Report, supra note 164, at 11-12. Hospital Quality Incentive Demonstration, Fact Sheet, available at 182 Id. at 6, 11-12. http://www.cms.hhs.gov/researchers/demos/phqi/default.asp (last visited July 23, 2005). 183 Id. at 11-12. 211 See, e.g., Centers for Medicare & Medicaid Services, Medicare 184 Id. at 11, 13. "Pay for Performance (P4P)" Initiatives (Jan. 31, 2005), available at 185 District of Columbia Department of Health, Eligibility Requirements http://www.cms.hhs.gov/media/press/release.asp?Counter=1343 for AIDS Drug Assistance Program, available at (last visited July 25, 2005); Meredith B. Rosenthal et al., Paying for http://doh.dc.gov/doh/cwp/view,a,1371,q,598706.asp (last visited Quality: Providers' Incentives for Quality Improvement, 23 HEALTH July 23, 2005). AFFAIRS 127, 138 (Mar./Apr. 2004); Alan M. Garber, Evidence- Based Guidelines as a Foundation for Performance Incentives, 24 186 Id. at 11-12; The Access Project, Washington DC ADAP Formulary, HEALTH AFFAIRS 174, 174-75, (Jan./Feb. 2005). available at http://www.atdn.org/access/states/dc/drugs.html (last visited July 18, 2005). 187 Washington DC ADAP Formulary, supra note 186; The Access Project, Connecticut ADAP Formulary, available at http://www.atdn.org/access/states/ct/drugs.html (last visited July 18, 2005). 188 Office of the Inspector General, Audit of the Department of Health HIV/AIDS Administration Office (OIG No. 04-2-05HC) 18 (June 22, 2005), available at http://oig.dc.gov/news/view2.asp?url=release%2FHIV%5FAIDS%5 FFINAL%5F6%2D16%2D05%2Epdf&mode=audit&archived=0&mon th=00000 (last visited July 23, 2005) [hereinafter "OIG Audit of HAA"].
56 HIV/AIDS IN THE NATION'S CAPITAL PART 2: CHAPTER V HIV PREVENTION
CHAPTER INFORMATION: BACKGROUND Routine HIV Testing HIV Prevention Tools Rapid Testing Advancing HIV Prevention (AHP) Condom Distribution Testing and Counseling Sexually Transmitted Disease Prevention and Treatment Testing Availability Traditional versus Rapid Testing Prevention Case Management Pre- and Post-test Counseling Training for Prevention Case Managers Condom Distribution Coordination of Prevention Case Sexually Transmitted Disease Managers with Ryan White Prevention and Treatment Case Managers Prevention Case Management SUMMARY OF RECOMMENDATIONS FINDINGS AND RECOMMENDATIONS CONCLUSION Testing
DC APPLESEED CENTER 57 Continuous surveillance of the effectively address HIV/AIDS. Recommendations include the promotion HIV/AIDS epidemic and an of routine and rapid HIV testing, increased condom distribution, and expanded STD understanding of the relevant Clinic services. Subsequent chapters discuss risk behaviors are necessary to prevention recommendations related to specific populations, including youth, drug formulate effective prevention users, and the incarcerated. interventions.212 Prevention interventions aim to modify an individual's behavior in order to BACKGROUND reduce the risk of contracting HIV PREVENTION TOOLS or infecting others with the virus. HIV prevention aims to avoid new HIV A number of HIV prevention infections. According to the CDC, successful "HIV prevention efforts must interventions have been be comprehensive and science-based."214 A comprehensive HIV prevention program is scientifically proven to modify based on surveillance, community planning, behavior and reduce the and education, and includes CDC-endorsed 213 interventions such as: HIV counseling, transmission of HIV. Successful testing, and referrals; health education; interventions promote harm/risk reduction; and capacity-building activities.215 responsible decision making by Commonly used HIV prevention tools include all individuals, so that they can the following: avoid engaging in risk behavior. z HIV prevention counseling, testing, and referral (CTR) are client-centered services Such prevention efforts are a delivered to persons who undergo anonymous or confidential HIV testing. critical component of a The services aim to identify an individual's comprehensive response to HIV status and risk behaviors and make appropriate referrals. the HIV/AIDS epidemic. z Harm/risk reduction is an intervention aimed at reducing the risk of HIV One effective way of promoting prevention transmission by injection drug use is through HIV testing programs. Such and/or sexual behavior. Examples of programs identify people who are infected harm reduction interventions include the with HIV so that they can obtain medical promotion of the use of condoms to care and other services. In addition, testing prevent sexual transmission of HIV and provides an opportunity to counsel the use of clean syringes to prevent HIV-positive and HIV-negative individuals transmission among IDUs. about behavior modification and z Outreach activities are services delivered risk-reduction strategies so that individuals to persons at high risk for HIV in places can take responsibility for avoiding they are likely to gather or frequent. Such transmission of the virus. outreach is aimed at individuals and often This chapter describes HIV prevention is provided in locations not directly related tools, testing and counseling, prevention to HIV prevention or health services, such case management, and STD prevention. as bars and clubs. Furthermore, this chapter explains how z Partner counseling and referral services the District's prevention efforts need to involve confidential and voluntary be broadened and strengthened to more notification of an HIV-positive individual's
58 HIV/AIDS IN THE NATION'S CAPITAL past and present sex or syringe-sharing paradigm has several implications for partners of possible exposure to HIV. In funding of HIV prevention programs in the addition, a partner may receive counseling District and may affect the specific types and education on how to avoid HIV and of interventions that are used in prevention STD infection. programs. z Social marketing uses commercial The new AHP initiative prioritizes marketing techniques to promote HIV interventions aimed at people living with prevention in a population or sub- HIV – "prevention with positives."222 In population. These techniques are aimed connection with this shift in focus to HIV- at "selling" socially beneficial ideas, positive individuals, the CDC has issued behaviors, and practices, and may be recommendations for incorporating HIV applied to all types of HIV prevention prevention into the routine medical care interventions. Social marketing may of persons living with HIV.223 These include the distribution of brochures recommendations focus on three major and educational materials.217 areas: risk screening; behavioral interventions; and partner counseling z Prevention case management involves 224 multiple one-on-one sessions of risk- and referral services. reduction counseling using a variety of strategies to change an individual's CDC'S ADVANCING HIV PREVENTION (AHP) sexual and other risk behavior. STRATEGIES: According to the CDC, each HIV prevention 1. Make HIV testing a routine part of medical care; intervention effort should have a defined audience, clearly stated goals and objectives, 2. Use new models for diagnosing HIV outside of traditional a focus on risk behaviors, and a specific medical settings; PREVENTION HIV CHAPTER V: setting.218 For example, an HIV prevention 3. Prevent new infections by working with HIV-positive persons program could be aimed at IDUs, with the and their partners; and goals of increasing condom use and use of sterile injection equipment.219 Such a 4. Decrease maternal-fetal HIV transmission. program may include counseling, clean syringe exchange, condom distribution, Centers for Disease Control and Prevention, Advancing HIV Prevention: Interim Technical Guidance education, or testing, and may be most for Selected Interventions 3. effective in a street setting or community venue where the targeted group can be found.220 Community organizations can play an TESTING AND COUNSELING important role in raising awareness of Testing for HIV status is a critical component HIV/AIDS prevention measures through of the AHP initiative and the effort to stem informal education and interactions. For the spread of HIV locally and nationwide. example, faith-based organizations and Since 2003, the CDC has recommended organizations serving high-risk populations that HIV screening be incorporated into the should discuss safe sex and abstinence and routine medical care offered in facilities reinforce prevention messages. In addition, serving individuals with high HIV prevalence, community organizations should distribute akin to cholesterol or other regular health condoms and educational materials. screenings.225 DC Appleseed did not evaluate the use The CDC estimates that up to 25 percent of or efficacy of particular interventions or those infected with HIV are unaware of their informal prevention efforts by community HIV status.226 Studies indicate that the organizations in the District. majority of individuals who know that they are HIV-positive take effective steps to ADVANCING HIV PREVENTION reduce the risk of spreading the infection to (AHP) others.227 Therefore, the earlier one discovers he or she is HIV-positive, the earlier that Recently, the CDC developed the "Advancing person is likely to adopt risk-reducing HIV Prevention" (AHP) initiative.221 This new behaviors that will help prevent the further
DC APPLESEED CENTER 59 by the DOH. Additionally, HAA funds five PREVENTION WITH POSITIVES IN THE CBOs to provide counseling, testing, and MEDICAL SETTING: referral services and operates an HIV testing z Risk Screening information hotline. – Behavioral risk screening TRADITIONAL VERSUS RAPID TESTING – Clinical (STD) screening The traditional test for HIV antibodies is – Pregnancy screening performed on a blood specimen.233 If the z Behavioral Interventions result is positive, a second test is used to 234 – Prevention messages in clinical setting confirm the positive result. Although the traditional testing methodology is highly – Reinforcement reliable, it involves significant disadvantages. – Dispel HIV/AIDS misconceptions The individual being tested must submit to – Target high risk individuals a blood draw, which may make some people reluctant to be tested. It also takes up to – Make referrals two weeks to obtain results from traditional z Partner Notification, Counseling, and Referral Services testing.235 The delay in obtaining test results from Advancing HIV Prevention Interim Technical Guidance for Selected Interventions 2-3. traditional testing is a serious drawback because individuals need to return to the spread of the virus. Testing also is extremely testing site for their test results. Of course, important to improving the health and quality the benefits of testing are lost if the person of life of those who are HIV-positive. The tested does not learn his or her HIV status. earlier in the course of infection that a In 2003, 33 percent of all those tested in person discovers he or she is HIV-positive, the District did not return for their HIV test 236 the better his or her chances are to obtain results. Traditional testing is particularly effective treatment to prevent or postpone problematic when an individual who has the onset of AIDS. Unfortunately, many tested positive for HIV does not return for people infected with HIV discover their HIV- the test results. In 2003, 18 percent of those positive status only after the infection has who tested positive for HIV in the District 237 progressed to AIDS and many opportunities did not return to receive their results. to treat the infection have been missed. Because many individuals fail to return for their traditional test results, post-test It can take six months or longer after the counseling and HIV treatment and care may time of infection for an individual to test be delayed or may never happen. positive for HIV.230 An individual who tests negative but has experienced even a single Fortunately, in recent years there have been known or possible exposure to HIV should important advances in rapid testing for HIV. generally be re-tested within six months after Rapid testing represents a major the last known possible exposure to the improvement over traditional testing. Instead virus.231 People who repeatedly engage in of requiring a blood draw, rapid tests can be high-risk behavior should be tested regularly. performed with only a few drops of blood from a finger stick or a sample of oral fluid.238 TESTING AVAILABILITY This allows rapid HIV testing to be performed in non-clinical settings, such as community HIV testing is performed by private doctors, centers and health fairs. Preliminary results hospitals, HAA, the STD Division, CBOs, and are available in 20 minutes,239 eliminating the at the District's detention facilities. Project need for individuals to return for results at a Orion, a mobile medical outreach unit funded later date, which has been a consistent jointly by HAA and APRA, travels to high-risk problem at testing sites. Prompt availability areas offering HIV testing, counseling, and of results significantly increases the number referral services.232 HAA also participates in of people tested who actually learn their HIV health fairs and community events, offering status.240 In addition, testing sites that have information and testing opportunities to the implemented rapid testing have reported an public. HIV counseling, testing, and referral services are offered at no cost to individuals
60 HIV/AIDS IN THE NATION'S CAPITAL increase of up to 30 percent in testing SEXUALLY TRANSMITTED among high-risk populations.241 DISEASE PREVENTION AND PRE- AND POST-TEST COUNSELING TREATMENT In order to be an effective HIV prevention CDC considers pre- and post-test counseling intervention, STD treatment must be to be essential components of HIV continuous and integrated into primary care prevention.242 During pre-test counseling, the delivery. In 1998, CDC's Advisory Committee counselor provides information concerning for HIV and STD Prevention (ACHSP) informed consent and confidentiality and reported strong evidence that early detection information about the test itself.243 The and treatment of STDs is an effective counselor also discusses the client's risk strategy for preventing HIV infection.252 behaviors and risk-reduction methods.244 ACHSP recommended expansion of existing During post-test counseling, the counselor screening and treatment programs, provides and explains the test results, particularly in areas with high STD and HIV discusses relevant risk and prevention rates and increased coordination between information, reviews risk-reduction methods, HIV and STD prevention programs. ACHSP and refers high-risk individuals to further also recommended routine STD screening prevention counseling.245 If the client's test and treatment in primary health care result is positive, post-test counseling settings, and in non-medical settings, such as includes treatment and case management correctional facilities and substance abuse referrals.246 Counselors also attempt to treatment centers. gather information to encourage partner notification.247 STD prevention is particularly important as an HIV prevention tool for certain CONDOM DISTRIBUTION populations. Due to the stigma and PREVENTION HIV CHAPTER V: misconceptions associated with HIV-positive One of the most basic and universally status in some communities of color, recognized prevention interventions to prevention education for STDs often is more reduce transmission of HIV is the promotion acceptable than HIV-specific education as of condom use. Condoms, when used a health care tool.253 Prevention education consistently and correctly during sexual messages that combine HIV, STD, and intercourse, can reduce the risk of unwanted pregnancy may be particularly transmitting and contracting HIV and other effective with young people.254 Additionally, 248 STDs. Studies have shown that male STD prevention can be an important HIV condoms are up to 95 percent effective in prevention tool for women because STD 249 reducing the transmission of HIV. Female infections increase their vulnerability to HIV, condoms are up to 97 percent effective in but may go undetected since they often reducing the risk of HIV infection when are asymptomatic.255 used correctly and consistently.250 Efforts to reduce HIV transmission through PREVENTION CASE condom use have focused on expanding MANAGEMENT access to condoms, providing education on proper condom use, and promoting regular Prevention case management is a support and consistent use of condoms. The broad service for individuals who are at high risk distribution of condoms should be combined of transmitting or acquiring HIV, but who with targeted prevention interventions, such are having difficulty initiating or sustaining as peer education for sex workers, in order behavior that reduces or prevents HIV 256 to maximize the effectiveness of this transmission or acquisition. Unlike prevention method.251 prevention activities such as outreach and support groups in which staff may interact briefly with high-risk individuals, prevention case management involves multiple one-on- one sessions of risk-reduction counseling using a variety of strategies to change HIV risk behavior. Like traditional case managers,
DC APPLESEED CENTER 61 prevention case managers connect clients Currently, no District-wide strategy for with needed medical and psychosocial implementing routine HIV testing exists. services; but, unlike traditional case The District does, however, promote routine managers, prevention case managers focus testing of pregnant women on an opt-in specifically on services that influence HIV basis. HAA is in the process of revising its risk-taking (e.g., STD and substance abuse policy on the routine HIV testing of pregnant treatment). For example, an IDU "may have women to state explicitly that HIV testing difficulty benefiting from HIV risk-reduction should be provided on an opt-out basis. counseling without receiving substance Under an opt-out approach, a pregnant abuse treatment."257 For individuals who are woman is informed that an HIV test will be HIV positive, prevention case management is performed unless she declines the test. The most effective when prevention interventions opt-out approach leads to a greater number are coordinated in close collaboration with of tests compared with an opt-in approach, Ryan White case managers.258 in which the client is asked if she would like to undergo the test.265 HAA should expedite the revision of the policy on HIV testing of pregnant women. FINDINGS AND In addition to revising the policy for pregnant women, HAA should broaden routine testing RECOMMENDATIONS to include high-risk populations. Although testing is available at the STD Clinic and TESTING APRA sites, HAA should take immediate steps to collaborate with the STD Clinic, ROUTINE HIV TESTING APRA substance abuse detoxification and HIV testing presents an opportunity to treatment centers, the District TB Clinic, and educate individuals about HIV prevention DMH-funded providers to ensure that HIV practices and to refer HIV-positive individuals testing is offered routinely to all clients, given to care services. Detection of HIV infection the high-risk populations being served. HAA in the early stages of the disease followed also should collaborate with the MAA and by prompt entry into care can lead to timely the Alliance to promote and ensure that HIV initiation of an appropriate treatment testing is a routine part of primary medical regimen.259 Treatment slows the progression care for those with public health coverage. of HIV to AIDS and increases survival rates In addition, HAA should work with the Board of those living with AIDS.260 The CDC's AHP of Medicine and the Medical Society to Initiative recommends implementation of promote testing at all medical settings for routine testing, which the CDC defines as the privately insured. ensuring "that all healthcare providers include Furthermore, HAA should promote routine HIV testing, when indicated, as part of testing in emergency rooms. Recent studies routine medical care on the same voluntary of pilot programs in Atlanta and Boston basis as other diagnostic and screening support the provision of routine testing in tests."261 emergency rooms in high-risk prevalence Routine testing was found to be cost- areas.266 In Atlanta, the number of patients effective in two recent studies published in tested, the number of HIV infections the New England Journal of Medicine. One detected, and the number of HIV-positive of the studies estimates that routine HIV patients entering care were significantly testing generally would reduce the annual higher where routine testing was provided.267 transmission rate by slightly more than 20 A pilot project in Boston also indicated that percent.262 In addition, both studies indicate routine testing was more cost-effective than that routine testing extends survival by one- traditional self-referral testing.268 and-a-half years for the average HIV-positive The District may benefit from other ongoing patient.263 By reducing HIV transmission studies of routine testing. In April 2004, the rates and extending survival, routine testing CDC initiated demonstration projects in decreases the amount of productivity lost Wisconsin, Massachusetts, New York State, because of HIV infection.264 and Los Angeles County to implement
62 HIV/AIDS IN THE NATION'S CAPITAL widespread routine testing using rapid HIV Louisiana program has distributed about tests in "non HIV related" medical care 13 million condoms per year at various settings.269 The projects seek to develop locations, including hospitals, public and model programs that will identify barriers private clinics, salons, bars, and to effective routine testing and demonstrate restaurants.280 A study of the Louisiana the feasibility of implementing routine rapid program demonstrated that the availability HIV testing. The CDC will use the findings of condoms increased condom usage and from these projects to develop guidelines estimated that the saved medical costs from that can further inform the District's efforts preventing one new case of HIV/AIDS pays to expand routine HIV testing.271 for more than 1.5 million condoms.281 Among African Americans, the program was shown RAPID TESTING to be particularly effective, resulting in a 30 In addition to promoting routine testing, the percent increase in condom use. Overall, the District should ensure widespread availability program was estimated to have prevented of rapid testing. HAA began to offer rapid 170 HIV infections in the program's first testing in 2003, and some CBOs began three years, resulting in a potential savings offering rapid testing in late 2004.272 HAA of $33 million in medical care costs.282 Based currently offers the rapid test at its office, on Lousiana's experience, an expanded and provides funding for rapid testing at two condom distribution program may be an CBOs.273 In 2005, HAA also plans to train extremely cost-effective means of reducing three additional CBOs to provide rapid HIV transmission in the District. testing.274 HAA estimates that, in 2005, In December 2003, the Acting Director of HAA and these organizations collectively HAA publicly announced that HAA would will administer 10,000 rapid tests.275 Rapid distribute 550,000 male condoms, 45,000 testing also is available at many CBOs dental dams, and 30,000 female condoms PREVENTION HIV CHAPTER V: through direct funding from the CDC and throughout the city during 2004.283 At that SAMSHA.276 In 2005, HAA and APRA time, HAA began a condom distribution implemented a Rapid HIV Testing Initiative for initiative called "Safe-in-the-City" to distribute high-risk populations, which the Bureau of condoms and install condom machines in 14 STD is expected to join later this year.277 local bars and clubs.284 Despite the stated DOH should continue efforts to conduct rapid distribution goal, HAA staff estimates that HIV testing at all District facilities, including 140,000 condoms were distributed through the STD Clinic, all APRA sites, the TB Clinic, the Safe-in-the City Initiative and 120,000 to and the D.C. Jail. In addition, HAA should 150,000 through outreach efforts at health provide training so that all grantees may fairs and other events in 2004.285 Due to implement rapid testing. recent funding cuts, the initiative has been Implementation of rapid testing should save reduced to four large "mainstream" clubs for the District money, since rapid tests cost 2005.286 In addition, HAA staff reports that less than traditional tests. One manufacturer HAA provides condoms for distribution in quoted the cost of the rapid test at $17 per beauty shops in the District.287 test, whereas its traditional oral test costs Given the high local AIDS rates and the $24 per test.278 In addition, a 2003 study that scientifically proven effectiveness of condom analyzed the cost of administering HIV tests use in preventing HIV transmission, condom suggests that rapid testing is significantly distribution should be a priority of the cheaper than traditional testing.279 District. At best, HAA distributed 290,000 condoms last year, about 50 percent of CONDOM DISTRIBUTION HAA's own projected target. Other cities, such as New York City, are giving a very high The District's condom purchasing and priority to condom distribution in a variety distribution efforts require expansion and of venues, including nightspots, clinics, improvement. Widespread, regular condom barbershops, beauty salons, movie theaters, distribution is a proven, cost-effective hotels, hospital emergency rooms, prevention intervention, as demonstrated by government offices, and public restrooms.288 a state-wide condom distribution and social marketing program in Louisiana. The
DC APPLESEED CENTER 63 In addition to increasing its own distribution organizations, universities, and clinics that initiatives, HAA should develop a centralized provide STD prevention and care services mechanism for all CBOs to obtain condoms to District residents.297 Outreach and free or at cost on a regular basis. HAA staff education are provided through community indicates that all HAA prevention grantees health fairs, training for health care workers receive a budgeted amount for the purchase and counselors, and STD prevention of condoms.289 In addition, HAA staff reports workshops with DCPS students and that any provider or agency working with community groups.298 infected or at risk populations also can get The DOH's STD Clinic is the only publicly- 290 condoms from HAA. CBOs have reported funded clinic in the District. The clinic difficulty obtaining condoms and female provides free STD screening, treatment, and condoms from HAA on a regular basis, referrals to all District residents.299 Because 291 however. Information on the availability of the STD Division does significant HIV condoms to CBOs is not clear. HAA should screening at the Clinic, HAA funds 11 of the have a mechanism for CBOs and other STD Division's positions.300 The STD Clinic District agencies to order free condoms is located on the grounds of the former D.C. through HAA's website. New York City's General Hospital and can be difficult to find Bureau of HIV/AIDS allows CBOs to order for those who are not already familiar with its up to 10,000 condoms at a time at no cost location. The STD Division should promptly 292 through the Bureau's website. When New publicize the Clinic's services and location. York recently expanded its condom In addition, DOH should evaluate the need distribution program, Ansell Healthcare, to extend hours and increase the number of the manufacturer of Lifestyles® condoms, service locations. donated 100,000 condoms to the city's efforts.293 A representative from a major According to STD Clinic staff, HIV testing is 301 condom manufacturer indicated that HAA routinely offered at the Clinic. However, could negotiate for discounted prices on bulk HIV testing is conducted on an opt-in basis purchases of condoms,294 thus maximizing in which the client is asked if he or she the use of available funds. Furthermore, the would like to be tested. Yet, as discussed District may be able to obtain a large quantity previously, an opt-out approach has been of free condoms from a manufacturer, as found to be more effective at increasing the did New York. number of clients who are tested. In fact, syphilis testing is conducted at the STD In addition to improving coordination with Clinic on an opt-out basis in which the client CBOs, HAA should coordinate with other is informed that the test will be performed District agencies providing services to high- unless the client declines. The STD Clinic risk populations, such as APRA, DMH, and should take steps to ensure that HIV testing DOC, to ensure regular condom distribution. is conducted on an opt-out basis. Some mental health providers reported high demand among clients when free condoms Rapid testing currently is not offered at the are made available.295 Since there is no Clinic, and clients must wait two weeks to regular distribution of condoms to other receive results. As discussed, the two-week agencies and no easily identifiable wait often can lead to clients not returning mechanism for individual providers to order for their test results. The STD Division condoms directly from HAA, this demand reports that rapid testing will be is not regularly met. implemented at the STD Clinic by the summer of 2005. The STD Division should implement rapid testing as soon as possible, SEXUALLY TRANSMITTED particularly since, as explained previously, DISEASE PREVENTION AND rapid HIV testing is less expensive than TREATMENT traditional HIV testing. The STD Division of the DOH offers testing, The STD Clinic also provides a key treatment, outreach, education, and opportunity for clients to receive prevention surveillance services.296 The STD Division education regarding STDs and HIV. The Clinic also provides technical assistance, training, should ensure that all Clinic clients receive and free testing supplies to local
64 HIV/AIDS IN THE NATION'S CAPITAL counseling regarding STD and HIV prevention. SUMMARY OF RECOMMENDATIONS PREVENTION CASE Routine Testing. The District should develop MANAGEMENT a city-wide strategy for implementing routine The District uses CDC funds to support a testing. HAA should expedite revisions of the prevention case management program that HIV testing policy for pregnant women to targets high-risk groups.302 This prevention adopt explicitly an opt-out approach. Routine case management program, however, needs testing also should be implemented by improvement in training and coordination. District agencies serving high-risk populations such as the STD Clinic, the TB TRAINING FOR PREVENTION Clinic, and APRA detoxification and CASE MANAGERS substance abuse treatment centers. DOH Under the CDC's guidance standards, and HAA should promote routine HIV prevention case managers must be provided screening by private doctors and medical opportunities for regular training and facilities and provide pertinent information for development.303 In accordance with these effective test counseling. In addition, MAA standards, the 2003-2004 HIV Prevention and HCSNA should require providers to offer Plan stated that HAA would provide training routine HIV testing to the District's Medicaid on behavioral and social interventions to beneficiaries and Alliance enrollees. CBO staff through CDC-funded training Rapid Testing. HAA should expedite the centers.304 implementation of rapid HIV testing at all In mid-2004, HAA reported to the CDC that District facilities, including the STD Clinic, HAA's attempts to provide training on APRA sites, the TB Clinic, and the D.C. Jail. PREVENTION HIV CHAPTER V: HIV/STD prevention through the CDC-funded In addition, HAA should provide training so regional training centers had "proved difficulty that all CBOs may implement rapid testing. [sic] because of the long lead time needed HAA also should coordinate with DMH in by these organizations and lack of funding to order to implement rapid testing at DMH- fund the training activities when their CDC funded providers and St. Elizabeths Hospital. funding had run out."305 HAA also reported Condom Distribution. HAA should that "for small and new CBOs the scheduling significantly expand condom distribution of staff away from their agency for training efforts in the District. Condoms should be strained service provision."306 HAA should provided regularly in a variety of venues. provide regular, ongoing training for Furthermore, HAA should develop centralized prevention case managers. CBOs should mechanisms for all providers of HIV/AIDS participate in available training opportunities services and other District agencies to obtain and coordinate scheduling with HAA. free condoms. HAA should also coordinate with other District Agencies providing COORDINATION OF PREVENTION services to high-risk populations, such as CASE MANAGERS WITH RYAN APRA and DMH, to ensure regular condom WHITE CASE MANAGERS distribution to their providers and clientele. To avoid duplication of services, the CDC STD Prevention. The STD Clinic should recommends that prevention case managers ensure that all clients receive counseling and Ryan White case managers establish regarding STD and HIV prevention. DOH explicit relationships for coordination and/or should publicize the available services and integration of services.307 Together, a Ryan location of the STD Clinic. In addition, DOH White case manager and a prevention case should evaluate the need for extended hours manager can determine which services each and additional locations for the STD Clinic. should provide.308 The Case Management Prevention Case Management. HAA Operating Committee, which will be should ensure that prevention case described in Chapter VI, may be the most managers receive adequate specialized efficient way for the two types of case training on a regular basis. HAA also managers to coordinate their operations. should develop a system for providing
DC APPLESEED CENTER 65 better coordination between prevention case managers and Ryan White case managers.
CONCLUSION The District should adopt a more comprehensive prevention plan to address the HIV/AIDS epidemic. As will be discussed in further detail later in this report, the District also should increase and strengthen existing prevention interventions with substance abusers, youth in D.C. Public Schools, and the incarcerated.
ENDNOTES 225 Advancing HIV Prevention Interim Technical Guidance, supra note 221, at 7-14. 212 Prevention of HIV Transmission, supra note 14, at 1038. 226 Id. at 8. 213 Centers for Disease Control and Prevention, HIV Prevention Strategic Plan through 2005, available at 227 Incorporating HIV Prevention into the Medical Care of Persons http://www.cdc.gov/hiv/partners/PSP/Prevention.htm (last visited Living with HIV, supra note 223, at 1. July 15, 2005) [hereinafter "HIV Prevention Strategic Plan 228 See id. at 7. through 2005"]. 229 See id. 214 Id., available at http://www.cdc.gov/hiv/partners/PSP/Elements.htm (last visited 230 Centers for Disease Control and Prevention, Revised Guidelines for July 15, 2005). HIV Counseling, Testing and Referral, 50 MORBIDITY & MORTALITY WKLY. REP. RECOMMENDATIONS & REP. 1, 34 (Nov. 9, 2001), 215 Id. available at 216 See HIV Prevention Interventions, Presentation to HIV Prevention http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5019a1.htm (last Community Planning Group Meeting (July 10, 2003). visited July 23, 2005) [hereinafter "Revised CDC Testing Guidelines"]. 217 See Baltimore City Council, Commission on HIV and AIDS Prevention and Treatment, Final Report 18 (Apr. 9, 2002), available 231 Id. at http://www.baltimorecitycouncil.com/HIV_AIDS_report.pdf (last 232 HIV/AIDS Administration, District of Columbia Department of visited July 15, 2005) [hereinafter "Baltimore HIV/AIDS Report"]. Health, Application to the Centers for Disease Control and 218 Centers for Disease Control and Prevention, Core Elements of Prevention for CY2005 HIV Prevention Projects 5 (Oct. 1, 2004) Health Education and Risk Reduction Activities, HIV HEALTH [hereinafter "D.C. Interim Progress Report"]. EDUCATION AND RISK REDUCTION GUIDELINES (Apr. 1995), 233 See Revised CDC Testing Guidelines, supra note 230, at 30-31. available at http://www.cdc.gov/hiv/HERRG/considerations.htm#2 (last visited July 25, 2005). 234 See id. at 31. 219 See, e.g., Health Education Training Centers Alliance of Texas – 235 See id. at 28. San Antonio, University of Texas Southwestern Medical Center – 236 Ivan Ortiz Torres, District of Columbia Department of Health, Health Dallas, and the Texas Department of Health, Fact Sheets of Department Final Report: Program Announcement 99004 at 2 Effective HIV Prevention Interventions 6, available at (Apr. 15, 2004). http://www.tdh.state.tx.us/hivstd/ta/finalifsdocument.doc (last visited July 23, 2005). 237 Id. 220 See id. 238 Bernard M. Branson, Associate Director for Laboratory Diagnostics, Division of HIV/AIDS Prevention, Centers for Disease Control and 221 See Centers for Disease Control and Prevention, Advancing HIV Prevention, Rapid HIV Testing: 2005 Update (2005), available at Prevention: Interim Technical Guidance for Selected Interventions http://www.cdc.gov/hiv/rapid_testing/index.htm#overview (July 3, available at 25, 2005). http://www.cdc.gov/hiv/partners/AHP/AHPIntGuidfinal.pdf (last visited July 23, 2005) [hereinafter "Advancing HIV Prevention 239 Id. Interim Technical Guidance"]. 240 Centers for Disease Control and Prevention, Update: HIV 222 See id. at 2-3. Counseling and Testing Using Rapid Tests – United States, 1998, 47 MORBIDITY & MORTALITY WKLY REP. 211-15 (Mar. 27, 1998), 223 See Centers for Disease Control and Prevention, Incorporating HIV available at Prevention into the Medical Care of Persons Living with HIV, 52 http://www.cdc.gov/mmwr/preview/mmwrhtml/00051718.htm (last MORBIDITY & MORTALITY WKLY. REP. RECOMMENDATIONS & visited July 24, 2005). REP. 2-3 (July 18, 2003), available at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5212a1.htm (last 241 Telephone Interview with Public Health Sales Representative of visited July 25, 2005). OraSure Technologies (June 22, 2005). 224 See generally, id. 242 Revised CDC Testing Guidelines, supra note 230, at 14-20.
66 HIV/AIDS IN THE NATION'S CAPITAL 243 Id. at 12. 266 Effective HIV Case Identification Through Routine HIV Screening at Urgent Care Centers in Massachusetts, 95 AM. J. PUB. HEALTH 71, 244 Id. at 14. 71-73 (Jan. 2005); Centers for Disease Control and Prevention, 245 Id. at 15. Voluntary HIV Testing as Part of Routine Medical Care – 246 Id. at 22. Massachusetts, 2002, 53 MORBIDITY & MORTALITY WKLY. REP. 523, 523-26 (June 25, 2004), available at 247 Id. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5324a2.htm 248 National Institute of Allergy and Infectious Diseases, National (last visited July 24, 2005); Centers for Disease Control and Institutes of Health, Department of Health and Human Services, Prevention, Routinely Recommended HIV Testing at an Urban Workshop Summary: Scientific Evidence on Condom Effectiveness Urgent-Care Clinic – Atlanta, Georgia, 2000, 50 MORBIDITY & for Sexually Transmitted Disease (STD) Prevention, available at MORTALITY WKLY. REP. 538, 538-40 (June 29, 2001), available at http://www.niaid.nih.gov/dmid/stds/condomreport.pdf (last visited http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5025a3.htm July 21, 2005). (last visited July 24, 2005). 249 American Foundation for AIDS Research, The Effectiveness of 267 Routinely Recommended HIV Testing at an Urban Urgent-Care Condoms in Preventing HIV Transmission 1 (Jan. 2005), available at Clinic – Atlanta, Georgia, 2000, supra note 266, at 538-40, tbl. 1. http://www.amfar.org/binary-data/AMFAR_PUBLICATION/ 268 Voluntary HIV Testing as Part of Routine Medical Care – download_file/34.pdf (last visited July 24, 2005). Massachusetts, 2002, supra note 266, at 523. 250 Id. at 2. 269 See Centers for Disease Control, Advancing HIV Prevention 251 Id. Demonstration Project Awardees 2003, available at http://www.cdc.gov/hiv/partners/ahp_award2003.htm (last visited 252 Centers for Disease Control and Prevention, National Center for July 22, 2005). HIV, STD, and TB Prevention, Division of Sexually Transmitted Diseases, STD Prevention, HIV Prevention Through Early Detection 270 See id. and Treatment of Sexually Transmitted Disease - United States 271 See id. Recommendations of the Advisory Committee for HIV and STD Prevention, 47 MORBIDITY & MORTALITY WKLY. REP. 272 Interview with District of Columbia government official; In Brief: RECOMMENDATIONS & REPS. 1, 1-24 (July 31, 1998), The District, WASH. POST, July 27, 2004, at B03; D.C. Interim available at www.cdc.gov/nchstp/dstd/MMWRs/ Progress Report, supra note 232, at 5, 7; interview with District of HIV_Prevention_Through_Early_Detection.htm (last visited July 21, Columbia government official. 2005) [hereinafter "HIV Prevention Through Early Detection and 273 In Brief: The District, WASH. POST, July 27, 2004, at B3; D.C. Treatment of STD"]. Interim Progress Report, supra note 232, at 6-7; interview with 253 Univ. of California-San Francisco Center for AIDS Prevention District of Columbia government official. Studies, AIDS Research Institute, How Do HIV, STD and Unintended 274 D.C. Interim Progress Report, supra note 232, at 6-7; interview with Pregnancy Prevention Work Together?, available at District of Columbia government official. PREVENTION HIV CHAPTER V: http://www.caps.ucsf.edu/STD-HIV.html (last visited July 21, 2005). 275 D.C. Interim Progress Report, supra note 232, at 7. 254 Id. 276 Interview with District of Columbia government official. 255 HIV Prevention Through Early Detection and Treatment of STD, 277 Id. supra note 252, at 7. 278 Id. 256 National Center for HIV, STD, and TB Prevention, U.S. Department of Health & Human Services, HIV Prevention Case Management 279 D. Ekwueme et al., Cost Comparison of Three HIV Counseling and Guidance 3 (Sept. 1997), available at Testing Technologies, 25 AM. J. PREVENTIVE MED. 112, 112 http://www.cdc.gov/hiv/pubs/hivpcmg.htm (last visited (Aug. 2003). July 21, 2005). 280 See Deborah A. Cohen et al., Implementation of Condom Social 257 Id. at 6. Marketing in Louisiana , 1993 to 1996, 89 AM. J. PUB. HEALTH 204, 208 (1999) 258 Id. at 3. 281 Id. 259 Centers for Disease Control and Prevention, Late Versus Early Testing of HIV – 16 Sites, United States, 2000-2003, 52 282 Ariane Lisann Bedimo et al., Condom Distribution: A Cost-utility MORBIDITY & MORTALITY WKLY. REP. 581, 584 ( June 27, 2003), Analysis, 13 INT'L J. STD & AIDS 384, 384-92 (June 2002). available at 283 Avram Goldstein, District To Offer Condoms For Free; Dispensers in http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5225a2.htm Offices Aimed at Rise in AIDS, WASH. POST, Dec. 2, 2003, at B1. (last visited July 24, 2005). 284 Interview with District of Columbia government official. 260 Id. 285 Id. 261 Centers for Disease Control and Prevention, Advancing HIV Prevention: New Strategies for a Changing Epidemic (Sept. 4, 286 Id. 2003), available at http://www.cdc.gov/hiv/partners/AHP- 287 Id. brochure.htm (last visited July 21, 2005). 288 New York City Commission on HIV/AIDS, Draft Report: 262 Gillian D. Sanders et al., Cost-Effectiveness of Screening for HIV in Recommendations to Make NYC a National and Global Model for the Era of Highly Active Antiretroviral Therapy, 352 NEW ENG. J. HIV/AIDS Prevention, Treatment and Care 11 (May 19, 2005), MED. 570, 580 (Feb. 10, 2005). available at http://www.nyc.gov/html/doh/downloads/pdf/ah/ 263 Id. at 579; David A. Paltiel et al., Expanded Screening for HIV in the ah-nychivreport.pdf (last visited July 22, 2005). United States – An Analysis of Cost-Effectiveness, 352 NEW ENG. 289 Interview with District of Columbia government official. J. MED. 586, 593 (Feb. 10, 2005); see also Samuel A. Bozzette, Routine Screening for HIV Infection – Timely and Cost-Effective, 290 Id. 352 NEW ENG. J. MED. 620, 620 (Feb. 10, 2005). 291 Interview with District of Columbia provider. 264 Bozzette, supra note 263, at 620. 292 New York City Department of Health and Mental Hygiene, Condom 265 Centers for Disease Control and Prevention, 51 HIV Testing Among Distribution Program, Condom Order Form, Pregnant Women – United States and Canada, 1998-2001. 51 http://www.nyc.gov/html/doh/html/ah/ah-condoms.shtml MORBIDITY & MORTALITY WKLY. REP. 1013, 1013-16 (Nov. 15, (last visited July 22, 2005). 2002), available at 293 Press Release, Ansell Healthcare, Lifestyles® Condoms Protecting http://www.cdc.gov/mmwr/PDF/wk/mm5145.pdf (last visited New York City (May 3, 2005), available at July 21, 2005). http://www.natap.org/2005/newsUpdates/050505-04.htm (last visited July 22, 2005).
DC APPLESEED CENTER 67 294 Telephone Interview with Pat Balto, Vice President, Public Sector (Jan. 1999-Dec. 2003), submitted on April 15, 2004 to the Centers Sales, Ansell Healthcare (July 6, 2005). for Disease Control and Prevention, at Attachment 2 [hereinafter "Final Progress Report"]. 295 Interview with District of Columbia provider. 303 HIV Prevention Case Management Guidance, supra note 256, at 296 Interview with District of Columbia government official. 26-27. 297 Id. 304 2003-2004 HIV Prevention Plan, supra note 53, at 7.1. 298 Id. 305 Final Progress Report, supra note 302, at 24. 299 Id. 306 Id. 300 Id. 307 Id. at 27-28. 301 Id. 308 Id. at 28. 302 HIV/AIDS Administration, District of Columbia Department of Health, Final Progress Report for Program Announcement 99004
68 HIV/AIDS IN THE NATION'S CAPITAL PART 2: CHAPTER VI HIV/AIDS TREATMENT AND CARE
CHAPTER INFORMATION: BACKGROUND Training for Case Managers Health Care Needs FINDINGS AND Medical Care RECOMMENDATIONS Prescription Drugs Comorbidities Comorbidities Mental Illness Substance Abuse Tuberculosis Mental Illness Other Needs Hepatitis C Case Management Tuberculosis Training for Case Managers Other Needs Funding Case Management SUMMARY OF Case Management Operating RECOMMENDATIONS Committee (CMOC) Case Management Quality CONCLUSION Assurance Protocol
DC APPLESEED CENTER 69 Many people living with BACKGROUND HIV/AIDS struggle with multiple needs. Proper health care, HEALTH CARE NEEDS The health care needs of an individual living housing, food, income, and with HIV/AIDS can be complex and may transportation are necessary require a wide variety of services and care. The existence of comorbidities such as to effectively manage and treat substance abuse, mental illness, Hepatitis C, and TB are complicating factors in the their disease. However, treatment of individuals with HIV/AIDS.311 substance use and addiction, MEDICAL CARE mental health problems, limited Persons living with HIV/AIDS must receive access to health care and comprehensive medical care to manage and monitor both health complications directly support services, and poverty associated with HIV/AIDS or antiretroviral often result in these needs being medications, as well as other concurrent medical conditions.312 Patients with HIV/AIDS unmet. Results from a 1996-1997 generally require more extensive medical study found that more than one- screenings, examinations, and monitoring, particularly those taking medications to treat third of people studied living complications stemming from HIV/AIDS.313 The medical provider coordinates a patient's with HIV delayed or did not treatment, including any necessary referrals obtain medical care because to specialists, and ensures continuity of care.314 In addition, the medical provider of other needs, including food, should educate the patient about HIV/AIDS clothing, and housing, or barriers and how to reduce the risk of transmitting HIV to others.315 such as transportation, Given the social, economic, cultural, and employment obligations, or psychological challenges associated with 309 HIV/AIDS, medical care for persons with severe illness. Low-income HIV/AIDS can be extremely complex. In the persons have less access to most successful treatment relationships, doctors must be aware of existing resources health care and, perhaps as a in the community in order to make appropriate referrals for their patients and consequence, may have poor must work to develop a strong patient-doctor health outcomes.310 relationship in which confidentiality and cultural competence are present.
This chapter describes the treatment and PRESCRIPTION DRUGS care required by individuals living with People with HIV/AIDS need a variety of drugs HIV/AIDS and the types of services provided to treat the disease itself and associated by the District. Because individuals living comorbidities, side effects, and opportunistic with HIV/AIDS often face multiple health infections. The cost of antiretroviral drug challenges, this chapter recommends greater therapy alone can be more than $12,000 per coordination of treatment and care and year for a single patient, not including the augmented case management services. cost of medication for other opportunistic infections or side effects.316 When the HIV/AIDS epidemic was first recognized in 1981, patients diagnosed with AIDS typically lived for one or two years with
70 HIV/AIDS IN THE NATION'S CAPITAL limited treatment options.317 As mentioned previously, the picture of the HIV/AIDS Factors with a negative impact on adherence to epidemic changed dramatically in 1996, with drug therapy: the introduction of HAART.318 HAART often z Lack of education about HIV disease reduces viral loads, which can help slow transmission, lengthen the time to the onset z Denial, anxiety, or depression of AIDS, and increase life expectancy.319 z Alcohol or drug use HAART can be effective in the treatment of z Poor social situation individuals who have HIV as well as those who have developed AIDS.320 Many experts z Inadequate health insurance believe that the introduction of HAART z Number of medications or pills therapy played a critical role in reducing the z Frequency of dosing AIDS death rate in the United States.321 In z Stringent dosing requirements 1997 alone, the AIDS death rate in the U.S. dropped 47 percent.322 z Presence of side effects Despite the positive impact on the life z Poor clinician-patient relationship expectancy of those with HIV, HAART can cause severe side effects, including Judith A. Aberg et al., Primary Care Guidelines for the Management of Persons Infected with Human neurological disturbances, dizziness, fatigue, Immunodeficiency Virus: Recommendations of the HIV Medicine Association of the Infectious Disease Society of America, 39 CLINICAL INFECTIOUS DISEASES 609, 609 (2004). weight gain, skin rashes, nausea, diarrhea, and lack of appetite.323 The severity of side effects and depression often are major COMORBIDITIES CARE HIV/AIDS TREATMENTAND CHAPTER VI: factors in the failure of patients to adhere to drug therapy regimens.324 When associated Comorbidity refers to the existence of one with other needed medications, HAART or more chronic conditions in addition to a also can require administration of more primary disease. Comorbidities frequently than 20 assorted pills per day on an often- occur in people with HIV/AIDS and may complicated schedule, which makes complicate their treatment or hasten the 330 adherence difficult.325 New regimens have progression of the disease. For example, been and continue to be developed that drug interactions may occur among multiple require fewer pills and less frequent medications used to treat several diseases 331 dosing.326 and conditions. Common comorbidities include: Unfortunately, poor adherence to antiretroviral drug regimens can be SUBSTANCE ABUSE particularly problematic. HIV develops As will be discussed in Chapter VIII, resistance to drugs very rapidly. It is substance abuse is an important factor in suggested that 95 percent or greater the transmission of HIV and can be a serious adherence is required to maximize the obstacle to receiving proper health care. The effectiveness of drug treatment, and studies DOH estimates that more than one-third of have shown a marked increase in the reported AIDS cases in the District have development of drug resistance when been linked to substance abuse.332 An HIV- adherence drops below 90 percent.327 If positive person with a substance abuse antiretrovirals are not taken according to problem requires comprehensive treatment their precise instructions, the virus has more and care that addresses both conditions. opportunities to replicate, thus increasing Active drug or alcohol abuse may decrease the likelihood that a random mutation will an individual's adherence to drug therapy.333 result in a resistant form of HIV.328 As the Drug or alcohol abuse also can impact an virus becomes resistant to more types of individual's general health and ability to antiretroviral drugs, treatment options are receive proper treatment. reduced.329 Although critical to the therapy's success, strict adherence to a complicated MENTAL ILLNESS medication schedule is extremely difficult. Many individuals living with HIV/AIDS also suffer from mental illness. Nationally, an
DC APPLESEED CENTER 71 estimated 50 percent of those in HIV/AIDS cautiously, and liver function tests must be care have some form of mental illness.334 conducted in all patients co-infected with 348 Individuals with persistent or severe mental Hepatitis C. illnesses may be at increased risk for HIV. TUBERCULOSIS The mentally ill are generally more likely to engage in high-risk sexual activity such as HIV infection suppresses the body's immune unprotected sex, having multiple partners, system, increasing an HIV-positive person's buying and selling sex, and failing to learn risk of developing TB. An HIV-positive the sexual history of their partners.335 individual who contracts TB is 100 times more likely to develop active TB than a TB- Mental illness not only affects the infected person who does not have HIV.349 transmission of HIV but may also hinder Drug interactions also are a problem for the access to health care required by individuals treatment of people co-infected with HIV and living with HIV/AIDS.336 Treatment of the TB, and patients often experience adverse underlying mental illness is an important reactions because the preferred treatments precursor to successful HIV/AIDS treatment: of each disorder may not be compatible.350 if an individual is receiving treatment for mental illness, adherence to HIV/AIDS OTHER NEEDS medication is more likely.337 HIV-positive individuals taking medication for a mental In addition to proper treatment, sufficient illness must be properly monitored, because nutrition, transportation, housing, and income serious depression or other mental health are critical to effectively managing HIV/AIDS disorders may be exacerbated by certain and maintaining optimal health. For a person medications for HIV/AIDS.338 living with HIV/AIDS, poor nutrition may result in increased vulnerability to HEPATITIS C opportunistic infections.351 Poor nutrition also can have a negative impact on medication Hepatitis C virus is a common comorbidity efficacy and adherence, ultimately for those infected with HIV.339 Hepatitis C accelerating the progression of HIV to can be transmitted through bodily fluids and AIDS.352 Reliable transportation is necessary blood (typically through injection drug use) to enable people with HIV/AIDS to regularly and can lead to cirrhosis (liver scarring), liver access proper health care. Stable housing failure, liver cancer, and death.340 As many as has been found to promote improved health 40 percent of all people living with HIV/AIDS status, sobriety, or decreased use of may also be infected with Hepatitis C.341 nonprescription drugs, and the potential for Among HIV-positive IDUs, the prevalence of people living with HIV/AIDS to return to Hepatitis C ranges between 50 percent and work.353 Recent studies have also found that 90 percent.342 access to stable housing increases the ability Hepatitis C-induced liver disease can be of a person with HIV/AIDS to access progressive, with cirrhosis developing in 20 comprehensive health care and adhere to percent to 30 percent of individuals.343 In complex HIV/AIDS drug therapies.354 individuals co-infected with HIV, Hepatitis C However, because a significant number of progresses more rapidly and there is a higher HIV-positive individuals have limited financial prevalence of cirrhosis.344 Also, the interval resources, many important needs may not between Hepatitis C infection and cirrhosis be met. Sufficient income support is an is significantly shorter for individuals infected important resource for many people infected with HIV.345 Recent studies also have with HIV or living with AIDS. Low-income reported that Hepatitis C infection might individuals living with HIV/AIDS may qualify accelerate the progression of HIV to AIDS, for direct monetary assistance, food stamps, but the evidence is not conclusive.346 A and health insurance. People with HIV/AIDS common and very challenging consequence may also qualify for disability benefits from of Hepatitis C co-infection is the inability to the Social Security Administration. The tolerate certain HIV/AIDS medications District also provides some transportation because of the potential for liver toxicity.347 services to people living with HIV/AIDS.355 Because of these concerns, HIV/AIDS In addition, HOPWA funding is available for medications should be administered housing-related assistance.356
72 HIV/AIDS IN THE NATION'S CAPITAL CASE MANAGEMENT CASE MANAGEMENT QUALITY ASSURANCE PROTOCOL As discussed above, persons with HIV/AIDS typically have complex health and social In an effort to improve case management needs during the course of their illness. Case service delivery throughout the District, management is a service that keeps persons the CMOC created a Quality Assurance with HIV/AIDS linked to a continuum of subcommittee to improve and amend the health, mental health, social, and educational Case Management Protocol used by services and therefore assists in their ability HIV/AIDS case management agencies to function independently with an improved funded by Ryan White. This protocol is the quality of life.357 Because of the multiple result of "best practice" standards gathered challenges faced by persons living with from a variety of HIV/AIDS service providers HIV/AIDS, the case manager must possess throughout the United States.364 The purpose skills and a knowledge base that of the protocol, which is now complete, is encompasses sensitivity to the psychosocial to provide a guide to ensure quality HIV/AIDS issues of drug use, chronic illness, poverty, case management services throughout the and discrimination.358 District.365 HAA recently approved the protocol, and some Ryan White case HIV-positive individuals who have case managers will be required to follow the managers have been shown to be more protocol as part of their grant agreements likely to take their antiretroviral medication once the Ryan White Planning Council and to obtain the necessary income support, approves the protocol.366 health insurance, home health care, and CHAPTER VI: HIV/AIDS TREATMENT AND CARE HIV/AIDS TREATMENTAND CHAPTER VI: counseling than those who lack case TRAINING FOR CASE MANAGERS managers.359 Special training and experience is required HIV/AIDS case management services are to become a successful HIV/AIDS case provided by many different types of CBOs manager.367 Case managers need to be up in the District and are supported by several to date on changes in available services, funding streams, including Ryan White, the increasing complexity of the needs of SAMHSA, HOPWA, and CDC. persons living with HIV/AIDS, and the range of resources available to meet those CASE MANAGEMENT OPERATING needs.368 In addition, they may need COMMITTEE (CMOC) additional training to work with client The CMOC was created several years ago by populations that are new to them or have a group of approximately six case managers special needs, or to sharpen particular case who received Ryan White funding.360 The management skills.369 impetus for the CMOC was the perceived need among this small group of case managers for peer support.361 Over the years, as HAA began funding larger numbers FINDINGS AND of case managers, HAA began to provide logistical support for the CMOC and made RECOMMENDATIONS attending CMOC meetings mandatory for certain case managers.362 COMORBIDITIES Representatives of the various HIV/AIDS case management organizations funded MENTAL ILLNESS by Ryan White in the District currently Nationally, an estimated 50 percent of participate in the CMOC. The CMOC patients receiving HIV/AIDS care also suffer meets monthly to address issues such from some form of mental illness.370 as coordination and duplication of case Currently, the comorbidity rate in the District management efforts, assessment of is unknown, and the District currently has changing needs within the HIV/AIDS no mechanism to track the number of community, and discussion of policy dually-diagnosed residents. Such data are 363 and practice issues. necessary to formulate effective prevention
DC APPLESEED CENTER 73 interventions and also to appropriately not performed for those who have been allocate resources for care. exposed to TB but are not found to have A significant barrier to serving the dually active TB. DOH should develop and enforce diagnosed in the District is the lack of a policy that all individuals who test positive coordination between HAA and DMH. for TB exposure or active TB at the District Increased cooperation is imperative to TB Clinic should be tested for HIV. The connect DMH clients with available HIV/AIDS cost-effectiveness of routine testing was resources, such as HIV/AIDS medications discussed in Chapter V. through ADAP.371 Mental health providers in In terms of surveillance, the District does the District also have reported difficulties not compile statistics on the prevalence of obtaining adequate specialized HIV/AIDS people living with both TB and HIV/AIDS. training for their clinical staff.372 Such training According to the CDC, the District reported should be made available to all mental health TB rates above the national average (5.1 providers. HAA and DMH should collaborate cases per 100,000 population) in 2003.376 to develop training materials regarding Specifically, there were 79 reported cases of HIV/AIDS and the complexities involved in TB in 2003, 82 in 2002, and 74 in 2001.377 The treating people with HIV/AIDS and mental prevalence of people with HIV/AIDS and TB health disorders. can only be estimated. CDC's minimum There also is a need for additional estimate of HIV co-infection in 1998-1999 collaboration between HAA and mental was approximately 10 percent of all persons 378 health providers regarding prevention with TB. services, including HIV counseling and testing. Because mental health providers OTHER NEEDS often have regular contact with their clients, DC Appleseed did not evaluate the efficacy such providers may have a good opportunity of food, transportation, housing, or other to provide these services. In addition, the supplemental programs. Thorough evaluation community-based mental health centers can of these programs' ability to meet District be a vehicle for other prevention efforts such needs may be necessary, particularly as the distribution of condoms, as discussed regarding housing. in Chapter V, and educational materials. Many persons living with HIV/AIDS, as well Two mental health providers noted a high as providers, cited housing shortages as a demand for condoms and educational major challenge in the District. Housing is materials among their clients.373 HAA should a serious concern in the District due to a coordinate with DMH or directly with mental severe shortage of affordable housing for health providers to ensure the availability of low-income people generally. In the District, condoms and educational materials at mental most of the housing units set aside for health treatment sites. Condom distribution individuals living with HIV/AIDS are and associated costs were addressed in transitional.379 Transitional housing often is Chapter V. limited to two years and typically has strict TUBERCULOSIS restrictions on tenant behavior, such as sobriety requirements.380 Yet, even these CDC Guidelines for HIV testing recommend transitional units are available only in limited that HIV testing and counseling be provided numbers.381 In general, there continues to be for those who are confirmed or suspected of a shortage of housing providers for those having TB, and that HIV testing be made living with HIV/AIDS.382 available on site at all TB clinics.374 However, it is unclear whether this actually occurs in Grant processing and reimbursement delays the District. A clinician at the District TB have been cited by some providers as the Clinic reported that if an individual has active major challenges in addressing the housing TB,375 he or she will receive an HIV test; shortage. Other comparable jurisdictions however, it could not be confirmed whether have been able to provide for the housing this is universally followed at the clinic or needs of persons living with HIV/AIDS in whether this is a DOH policy. Furthermore, their communities through a variety of the clinician indicated that HIV testing was means, including: legislated mandates requiring immediate housing placement for
74 HIV/AIDS IN THE NATION'S CAPITAL all persons with HIV/AIDS; specific local providers can bill Medicaid for case and federal funding allocation schemes for management services provided to Medicaid housing development and subsidies; beneficiaries, reducing the strain on Ryan comprehensive financial planning with White resources. The District has several housing providers; and the coordination of options for adding case management strong relationships with developers and services to its Medicaid benefits package. local banks.383 Such initiatives may be First, the District could receive its regular appropriate in the District to address the federal match by amending its State Plan housing needs of persons with HIV/AIDS. to include case management services for all beneficiaries. Alternatively, it could amend CASE MANAGEMENT the plan to target the services to specific beneficiaries or providers. Third, the District TRAINING FOR CASE MANAGERS could count the costs of case management services under its administrative budget Case managers report that they do not and receive only a 50 percent match from receive enough professional and in-service the federal government. By adding case training.384 Currently, the Quality Assurance management services to the Medicaid subcommittee of the CMOC provides package, the District would increase the training for members of the CMOC, with availability of Ryan White funding for other logistical support from HAA.385 But, as noted, services. the CMOC does not include all case managers. HAA should provide (or contract The District currently provides case
a third-party to provide) regular training for all management services to individuals enrolled CARE HIV/AIDS TREATMENTAND CHAPTER VI: of the District's HIV/AIDS case managers, in through the Ticket to Work and the Medicaid coordination with the QA subcommittee of Section 1115 waiver. The District's 1915(c) the CMOC or a new Needs Assessment waiver could be amended to provide case subcommittee. To guide the specific training management services. As of November offered by HAA, members of the CMOC and 2003, five states had requested or had HAA should conduct an annual assessment received approval for 1915(c) waivers to of training needs of case management staff. provide case management services to This process also should be informed by Medicaid-eligible persons with HIV or client satisfaction surveys in order to identify AIDS.387 areas in which additional training is needed. Finally, HAA should include training requirements in grants with a case management component. SUMMARY OF Some jurisdictions partner with local RECOMMENDATIONS universities and nonprofit organizations that have expertise in case management to Comorbidities. DOH should work to identify ensure that their HIV case managers receive and target people with comorbidities for adequate training. For example, case testing, treatment, and care. DOH also managers in New York and New Jersey have should improve the availability of data access to training and HIV case management regarding comorbidities. HAA and DMH certification programs at Columbia should collaborate to provide adequate University's Mailman School of Public Health training on HIV/AIDS issues to mental health and the University of Medicine and Dentistry workers. HAA also should facilitate of New Jersey.386 The District should explore prevention interventions, including testing partnering with a local university or and counseling, education, and condom organization to provide training for case distribution for the mentally ill at mental managers. health provider sites and St. Elizabeths Hospital. DOH should implement and FUNDING enforce a policy that all individuals who test positive for TB exposure at the District TB Currently, case management is funded Clinic or who have active TB be tested through Ryan White, but it should be added routinely for HIV. HAA also should increase to the Medicaid benefits package so that interagency collaboration to improve
DC APPLESEED CENTER 75 treatment and care for other comorbidities such as substance abuse and Hepatitis C. CONCLUSION Case Management. HAA should monitor People living with HIV/AIDS, particularly adherence to revised case management those with comorbidities, have complex protocols and provide case managers with needs that require comprehensive health regular substantive training and current care, case management services, housing information about available resources and assistance, and, often, food, income services for their clients. The District should maintenance, and transportation assistance. expand Medicaid benefits to include case Because various agencies in the District management, allowing providers to better oversee the provision of these services, maximize Ryan White funding. systematic interagency collaboration is needed.
ENDNOTES 322 Id. 309 Health Resources and Services Administration, Directions in HIV 323 Lake Snell Perry & Assoc., Inc., The Henry J. Kaiser Family Service Delivery & Care – A Policy Brief, Number 4: Reducing Foundation, The Healthcare Experiences of Women with HIV/AIDS: Barriers to Care 13 (2000). Insights from Focus Groups, Executive Summary 7 (Oct. 2003), available at http://www.kff.org/hivaids/3379.cfm (last visited July 310 Nicole Lurie et al., DC Primary Care Association Medical Homes 19, 2005). DC, Assessing the Primary Care Safety Net Needs and Health Disparities (Jan. 28, 2005), available at http://www.brookings.edu/ 324 Id. metro/gwrp/20050128_healthcare.pdf (last visited July 18, 2005). 325 HIV Infection and AIDS, supra note 2; American Cancer Society, 311 See generally Health Resources and Services Administration, A How is HIV/AIDS Treated? (2004), available at GUIDE TO PRIMARY CARE OF PEOPLE WITH HIV/AIDS (John G. http://www.cancer.org/docroot/CRI/content/CRI_2_4_4x_How_Is_ Bartlett et al., eds., 2004), available at http://hab.hrsa.gov/tools/ HIVAIDS_Treated.asp?sitearea (last visited July 19, 2005). primarycareguide/ (last visited July 18, 2005) [hereinafter "A GUIDE 326 Interview with District of Columbia provider. TO PRIMARY CARE OF PEOPLE WITH HIV/AIDS"]. 327 David L. Paterson et al., Adherence to Protease Inhibitor Therapy 312 Id. and Outcomes in Patients with HIV Infection, 133 ANNALS 313 Judith A. Aberg et al., Primary Care Guidelines for the INTERNAL MED. 21 (July 4, 2000); Ajay K. Sethi et al., Association Management of Persons Infected with Human Immunodeficiency between Adherence to Antiretroviral Therapy and Human Virus: Recommendations of the HIV Medicine Association of the Immunodeficiency Virus Drug Resistance, 37 CLINICAL INFECTIOUS Infectious Disease Society of America, 39 CLINICAL INFECTIOUS DISEASES 1112 (Oct. 15, 2003). DISEASES 609, 609 (2004), available at http://www.aidsetc.org/ 328 Bob Munk, Resistance to Anti-HIV Medications Part 2 (Nov./Dec. pdf/p02-et/et-02-01.pdf (last visited July 19, 2005) [hereinafter 2002), available at http://www.thebody.com/tpan/novdec_02/ "Primary Care Guidelines"]. resistance.html (last visited July 24, 2005) [hereinafter "Resistance 314 INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES, PUBLIC to Anti-HIV Medications"]. FINANCING AND DELIVERY OF HIV/AIDS CARE: SECURING THE 329 Id. LEGACY OF RYAN WHITE 80 (2004) [hereinafter "PUBLIC FINANCING AND DELIVERY OF HIV/AIDS CARE"]. 330 A GUIDE TO PRIMARY CARE OF PEOPLE WITH HIV/AIDS, supra note 311, at 18, 47-54. 315 Primary Care Guidelines, supra note 313, at 612. 331 New York State Health Department AIDS Institute, Criteria for the 316 ADAP Fact Sheet, supra note 162. Medical Care of Adults with HIV Infection: HIV Drug Interactions 317 National Institute of Allergy and Infectious Diseases, New 4C-1 (Aug. 2004), available at http://www.hivguidelines.org/ Treatments for HIV Infection: Prolonging and Improving Life 1 public_html/a-drug/a-drug.pdf (last visited July 25, 2005). (1999), available at http://www.niaid.nih.gov/publications/ 332 District of Columbia Department of Health, Special Services for discovery/hiv.htm (last visited July 19, 2005). Persons with HIV/AIDS, available at http://doh.dc.gov/doh/ 318 How Long Does It Take for HIV to Cause AIDS?, supra note 5. cwp/view,a,1374,q,575970,dohNav_GID,1803.asp (last visited July 24, 2005). 319 National Institute of Allergy and Infectious Diseases, Treatment of HIV Infection (2004), available at http://www.niaid.nih.gov/ 333 Jeffrey H. Hsu, Substance Abuse and HIV, 14 THE HOPKINS HIV factsheets/treat-hiv.htm (last visited July 19, 2005). REPORT 9 (July 2002), available at http://www.hopkins- aids.edu/publications/report/nl_02_july.pdf (last visited July 20, 320 HIV Infection and AIDS, supra note 2. 2005). 321 John Henkel, Attacking AIDS with a Cocktail Therapy, FDA 334 PUBLIC FINANCING AND DELIVERY OF HIV/AIDS CARE, supra note CONSUMER MAGAZINE (July-Aug. 1999), available at 314, at 42. http://www.fda.gov/fdac/features/1999/499_aids.html (last visited July 19, 2005).
76 HIV/AIDS IN THE NATION'S CAPITAL 335 American Psychiatric Association, Mental Health Treatment Issues 359 PUBLIC FINANCING AND DELIVERY OF HIV/AIDS CARE, supra note HIV Fact Sheet: HIV and People with Severe and Persistent Mental 314, at 79. Illness 1 (Jan. 1999), available at http://www.psych.org/aids/ 360 Interview with District of Columbia provider. spmi_factsheet.pdf (last visited July 25, 2005) [hereinafter "Mental Health HIV Fact Sheet"]. 361 Id. 336 Id. at 2. 362 Id. 337 Mental Health HIV Fact Sheet, supra note 335. 363 Interviews with District of Columbia government official and provider. 338 Baltimore HIV/AIDS Report, supra note 217, at 30. 364 Id. 339 Id. at 13. 365 Id. 340 Id. 366 Id. 341 Mandana Khalili, Coinfection with Hepatitis Viruses and HIV, HIV INSITE (Dec. 2004), available at http://hivinsite.ucsf.edu/ 367 Towards a Typology of Case Management, supra note 358. InSite?page=kb-05-03-04 (last visited July 20, 2005). 368 Interview with District of Columbia provider. 342 Id. 369 Id. 343 Id. 370 PUBLIC FINANCING AND DELIVERY OF HIV/AIDS CARE, supra note 344 Id. 314, at 42. 345 Id. 371 Interview with District of Columbia government official. 346 Centers for Disease Control and Prevention & the HIV Medicine 372 Interview with District of Columbia provider. Association/Infectious Diseases Society of America, Treating 373 Interviews with District of Columbia providers. Opportunistic Infections Among HIV-Infected Adults and Adolescents, 53 MORBIDITY & MORTALITY WKLY. REP. 374 Revised CDC Testing Guidelines, supra note 230, at 2, 7, 10, 57. RECOMMENDATIONS & REPS. 1-63 (Dec. 17, 2004), available at 375 Interview with District of Columbia government official. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5314a1.htm (last 376 Department of Health and Human Services, Centers for Disease visited July 24, 2005) [hereinafter "Treating Opportunistic Control and Prevention, 50 Years of TB Surveillance; Reported Infections"]. Tuberculosis in the United States, 2003, at 3 (Sept. 2004), available 347 Coinfection with Hepatitis Viruses and HIV, supra note 341. at http://www.cdc.gov/nchstp/tb/surv/surv2003/PDF/ CHAPTER VI: HIV/AIDS TREATMENT AND CARE HIV/AIDS TREATMENTAND CHAPTER VI: 348 Id. Surv_Report_2003_small.pdf. 349 PUBLIC FINANCING AND DELIVERY OF HIV/AIDS CARE, supra note 377 Id. at 63, 71. 314, at 47. 378 Id. at 23. 350 Treating Opportunistic Infections, supra note 346. 379 Interview with District of Columbia provider. 351 U.S. Agency for International Development, USAID Programs: 380 Id. HIV/AIDS and Nutrition (2003), available at http://www.usaid.gov/ 381 Id. our_work/global_health/aids/TechAreas/nutrition/ nutrfactsheet.html (last visited July 20, 2005). 382 Interviews with District of Columbia government officials and providers. 352 Id. 383 Interviews with HOPWA coordinators in Los Angeles, California 353 HIV/AIDS Housing, supra note 142. and New York, New York (Apr. 15, 2005). 354 Id. 384 Interview with District of Columbia provider. 355 D.C. CARE Consortium, LINC Linking Individuals Needing Care, 385 Id. available at http://www.dccare.org/dccare_programs.htm (last visited July 20, 2005). 386 Center for Continuing and Outreach Education, Division of AIDS Education, available at http://ccoe.umdnj.edu/aids/index.htm (last 356 U.S. Department of Housing and Urban Development, Housing visited July 21, 2005); NY/NJ AIDS Education and Training Center, Opportunities for Persons with AIDS (HOPWA) Program, available Welcome to the NY/NJ AIDS Education and Training Center, at http://www.hud.gov/offices/cpd/aidshousing/programs/ available at http://www.nynjaetc.org/ (last visited July 22, 2005). index.cfm (last visited July 25, 2005). 387 Centers for Medicare & Medicaid Services, Home and Community- 357 Interview with District of Columbia government official. Based Services Summary Report, available at 358 Philip Fleisher & Mark Henrickson, Towards a Typology of Case http://www.cms.hhs.gov/medicaid/services/regular.pdf (last Management, U.S. DEPARTMENT OF HEALTH & HUMAN visited July 24, 2005). SERVICES, available at http://hab.hrsa.gov/special/typology.htm (last visited July 20, 2005).
DC APPLESEED CENTER 77
PART 2: CHAPTER VII HIV PREVENTION IN D.C. PUBLIC SCHOOLS
CHAPTER INFORMATION: HIV/AIDS AMONG YOUTH SUMMARY OF RECOMMENDATIONS HIV PREVENTION IN DCPS The HIV/AIDS Education Program CONCLUSION Health and Physical Education School Health Programs COMPONENTS OF A SUCCESSFUL HIV PREVENTION PROGRAM Curriculum Professional Development Collaboration and Coordination Monitoring, Data Collection, and Evaluation DCPS HIV/AIDS AD HOC COMMITTEE
DC APPLESEED CENTER 79 Many young people have HIV/AIDS AMONG misconceptions about the health YOUTH risks associated with HIV/AIDS More than a quarter of Americans living with and have incomplete information HIV/AIDS became infected during their teen years.388 It is estimated that 50 percent of on the methods of protecting new HIV infections in the United States occur in individuals under the age of 25.389 themselves and the need for According to the District's 2004 Ryan White testing. As will be discussed, Title I grant application, an estimated 2,242 youth are infected with HIV in the youth in the District face serious Washington, D.C. Eligible Metropolitan risk of HIV infection due to Area.390 The 2003 Youth Risk Behavior Survey (YRBS) above-average rates of data indicated a decrease in the number of unprotected sex and substance District students that report having sex.391 However, youth in the District continue to use. Therefore, a targeted and report sexual and high-risk behavior at higher comprehensive HIV prevention rates than national averages.392 According to 2003 YRBS data for the District: program is imperative to provide z 64 percent of District students reported young people in the District with having sexual intercourse at least once the skills and information to (47 percent in U.S.); z 45 percent of District students reported protect themselves. Schools have having sexual intercourse with one or more people during the past three months the opportunity – and the – of those, 19 percent reported having had responsibility – to provide sexual intercourse under the influence of alcohol or drugs (34 percent and 25 age-appropriate HIV prevention percent in U.S.); education and support to z 25 percent of District students had sexual intercourse with four or more people students. during their life (14 percent in U.S.).393 In 2000, the District's pregnancy rate was This chapter will describe the HIV prevention 128 pregnancies per 1,000 women of 15 to programs that exist within the D.C. Public 19 years of age, higher than any state (the Schools (DCPS). This chapter recommends national average was 84 pregnancies per the development and implementation of 1,000).394 The CDC's 2003 STD Surveillance comprehensive standards for HIV/AIDS Report indicates that the District's STD rates education in the schools, evaluation of also are significantly higher than the national HIV/AIDS education services, improved averages. The national rate for gonorrhea in collection of data on HIV/AIDS services in 2003 was 116 reported cases per 100,000 of the schools, better coordination of HIV/AIDS the civilian population.395 The District's rate services within DCPS’ administrative offices, was 439 cases per 100,000, almost four and expanded communication with the public times the national average.396 Similarly, in and other agencies regarding DCPS 2003, the rate for chlamydia in the District HIV/AIDS’ program. was almost twice the national average (555 per 100,000 in the District as compared to 304 per 100,000 nationally), and the rate for primary and secondary syphilis cases was more than three times the national average (8.4 per 100,000 in the District as compared to 2.5 per 100,000 nationally).397 In the
80 HIV/AIDS IN THE NATION'S CAPITAL District in 2003, a total of 2,041 new cases administration which provide HIV/AIDS of chlamydia, gonorrhea, and syphilis were services to DCPS students and schools. diagnosed in persons under the age of 20.398 The previous year, youth under the age of 20 THE HIV/AIDS EDUCATION accounted for 38 percent of all new cases PROGRAM of chlamydia, 24 percent of new gonorrhea infections, and 7 percent of new syphilis The HIV/AIDS Education Program is funded cases in the District.399 directly by the CDC Division of Adolescent School Health (DASH) and receives no local As noted previously, substance use funding from DCPS or HAA. In fiscal year contributes to the risk of HIV and STD 2005, DCPS received $249,936 from the transmission, either because of transmission CDC for the HIV/AIDS Education Program. via infected syringes, or because the The same amount is projected for fiscal year influence of drugs and alcohol increases the 2006.404 While DCPS does not provide any likelihood of unprotected sex. Among youth local funding for this program, it does provide surveyed for the 1997 District of Columbia funding for the other offices described Youth Behavioral Risk Factor Survey, 71 below. The HIV/AIDS Education Program percent reported drinking alcohol, 52 percent serves all District public schools and is had used marijuana, and 25 percent had located at an elementary school in Southeast 400 obtained an illegal drug on school property. D.C. This office provides technical assistance According to 2003 YRBS data, 3.9 percent of in planning, developing, and implementing HPE I:HVPEETO NDC PUBLIC SCHOOLS HIV PREVENTION IN D.C. CHAPTER VII: District youth surveyed reported injection HIV/AIDS prevention programming in drug use during their lifetime, which is schools. According to DCPS' DASH grant comparable to the national median of 3.2 proposal, the office provides professional 401 percent. Further, 5.4 percent of District development to teachers in the use of students reported using heroin at least once CDC-approved HIV/AIDS curricula and limited in their lifetimes, as opposed to 3.3 percent training to CBOs. This office also works with 402 of students nationwide. Children's National Medical Center (CNMC) and the school nurses on the Adolescent AIDS Prevention Program, described below. Formerly, in the absence of a Health and HIV PREVENTION Physical Education Director, this office helped to coordinate access to schools for CBOs IN DCPS wishing to provide HIV/AIDS services. As with other aspects of HIV prevention, CDC provides funds and general guidance to HEALTH AND PHYSICAL school districts to combat the spread of HIV. EDUCATION CDC does not specify how schools should use the funds; rather, the agency allows The Health and Physical Education Director schools to create their own HIV prevention for DCPS is responsible for system-wide programs to specifically appeal to their target instruction in health and physical education. audience, consistent with local community In general, the Health and Physical Education and parental values.403 Given the topic's Director's primary responsibilities are to sensitivity, the CDC recommends that develop curricula, train teachers, and provide schools develop HIV/AIDS education other technical assistance to schools. The programs with participation from a wide Health and Physical Education Director works range of community groups. closely with the HIV/AIDS Education Program to provide training to teachers in the use of DCPS serves approximately 65,000 students CDC-approved curricula. This position had who attend 167 D.C. public schools and been vacant for about one year before it 14,000 who attend roughly 46 D.C. public was filled in April 2004. charter schools. A number of HIV prevention programs directly targeting students in the DCPS are described below. SCHOOL HEALTH PROGRAMS These programs are administered primarily The Director of School Health Programs is through three offices within DCPS' central DCPS' liaison for the CNMC School Nursing
DC APPLESEED CENTER 81 program. She is responsible for ensuring implemented uniformly in all schools policy compliance. This includes monitoring (although the Health and Physical Education the policies and procedures of school health Director hopes to establish such a programs, coordinating health services and curriculum). Instead, school health courses systems to meet compliance standards, and are expected to meet standards set by the organizing technical assistance based on American Association of Health Education. federal and District school health regulations. Teachers have been trained in the use of the The Adolescent AIDS Prevention Program association's standards; however, the school was created in 1992. Since 2001, this system will not formally adopt them until 407 program has been managed by the CNMC. later in 2005. DCPS students are required The steering committee for this endeavor to take Health and Physical Education consists of nurses, parent groups, clergy, through the 10th grade, but school principals public school administrators, and D.C. may choose the degree to which HIV Council members. An important part of this prevention is addressed. In fact, not all program involves condom distribution. At any schools have a health or physical education time during the school year, a high school instructor. student may obtain condoms from a nurse The District regulations require "health once the student has received counseling instruction within a planned, sequential, and instructions on condom use (on pre-K-12 comprehensive school health subsequent visits, the student is permitted education curriculum."408 Comprehensive to obtain condoms without further school health education is defined as "age counseling).405 appropriate instruction that improves the knowledge, skills, and behaviors of students so they choose a health-enhancing lifestyle and avoid behaviors that may jeopardize their COMPONENTS immediate or long-term health status."409 Health instruction must include information OF A SUCCESSFUL about HIV/AIDS and STDs, as well as human sexuality.410 However, there currently are no HIV PREVENTION system-wide standards or mandates for PROGRAM HIV/AIDS education at particular grade-levels, no tracking of HIV/AIDS education received In general, a successful HIV prevention by students, and no standards for the quality program for youth will have four of education they received. components: (1) a curriculum that meets Some schools, but not all, work with CBOs, community needs and standards; which provide various curricula. CBOs that (2) professional development for instructors are approved by the HIV/AIDS Education that is updated regularly to reflect Program or that receive federal funding use advancements in HIV knowledge and CDC-approved curricula.411 CDC-approved prevention strategies; (3) collaboration with curricula are all multi-session workshops other agencies and community organizations; with informational as well as skills-building and (4) monitoring and evaluation of program components. The CDC's guidelines on impact.406 DC Appleseed found major effective HIV-prevention education emphasize impediments to each component in DCPS’ age-appropriate, comprehensive curricula HIV prevention programming, which leaves that help students understand "the young people in the District vulnerable to relationships between personal behavior and HIV and other sexually transmitted infections. health."412 CDC-approved curricula include information on abstinence, HIV/AIDS CURRICULUM prevention through condom use, as well as DCPS is highly decentralized. Principals must information about transmission through meet standards and graduation requirements substance abuse. However, some CBOs – but otherwise have a great deal of control that have not received approval through the over what is taught in their schools and HIV/AIDS Education Program – have provided which staff positions are filled. Thus, DCPS "one-shot" HIV prevention sessions, often lacks a standardized curriculum that is simply providing PowerPoint presentations,
82 HIV/AIDS IN THE NATION'S CAPITAL to students.413 As will be discussed, DCPS as to assist these organizations in gaining lacks clear, consistently applied standards for access to schools. Yet, all of the CBO the programs operating in its schools. directors interviewed for this report raised serious concerns about the performance of PROFESSIONAL DEVELOPMENT the HIV/AIDS Education Program office. In fact, one local CBO that has provided HIV The Director of the HIV/AIDS Education prevention services in the schools for the last Program provides training for health five years had not even heard of the office or education teachers for credit toward graduate its director. In an interview in fall 2004, the and recertification requirements. This training Director of the HIV/AIDS Education Program is voluntary, and thus only a small number stated that she was informally responsible of teachers participate. Furthermore, the for coordinating access to schools with CBOs teachers who choose to participate may not and that this process would be facilitated by be the ones in greatest need of training. a workshop conducted at the beginning of Training for principals also is voluntary. DCPS’ the academic year for all CBOs interested in administrators have expressed concerns working within schools. Later, she reported about the manner in which some principals that this workshop did not occur and that treat HIV-positive students. In addition, responsibility for the workshop was moved school staff lacks information about to the office of the Health and Physical accessing social services for these students Education Director. 414 and their families. Currently, the responsibility for reaching out PUBLIC SCHOOLS HIV PREVENTION IN D.C. CHAPTER VII: to CBOs, approving CBOs to work in schools COLLABORATION AND (a new Memorandum of Understanding COORDINATION (MOU) process has been developed for this purpose), and developing standards for and The schools, the nurses, and the CBOs have monitoring CBO performance now falls to all expressed the need for better the Health and Physical Education Director. collaboration and coordination.415 CBOs have However, because the Director also is repeatedly encountered difficulty "getting working on the development of new District- into the schools." Some felt they were "not wide curriculum standards, it is questionable welcome" in the public schools and had to whether she will have time to adequately keep a low profile and work behind the perform these additional responsibilities, scenes. CBO staff expressed that oftentimes and whether working with CBOs is an it has been easier to work directly with a appropriate responsibility for this office. principal than to go through the HIV/AIDS Education Program. At the same time, it is At best, coordination of the various offices understandable that DCPS would like all would be challenging given the organizational providers to go through a centralized office and physical placements of the three offices. within DCPS, particularly given the sensitive The Health and Physical Education Director nature of HIV prevention programs. DCPS falls under the Curriculum Office of the Chief administrators have expressed frustration Academic Officer, while the Director of that CBOs do not contact their office, but School Health and Director of the HIV/AIDS rather, go directly into a school through the Education Program are under the supervision principal, making it difficult to discern which of the Assistant Superintendent for the schools have programs and which do not. Division of Student Affairs. The HIV/AIDS One DCPS administrator suggested that Education Program office is located at an CBOs need to be "less competitive" about elementary school in Southeast D.C., getting into certain schools and more willing while the other two are at DCPS' central to work with the school system to ascertain administration office. the needs of all schools. DCPS policies regarding coordination The Director of the HIV/AIDS Education between principals and the DCPS central Program has stated that the Program's administrative offices are also unclear. responsibilities include working in partnership Principals answer to their Assistant with CBOs to provide and enhance HIV/AIDS Superintendent and are not accountable prevention programming in schools as well to the HIV/AIDS Education Program. They
DC APPLESEED CENTER 83 are not required to report to the central duration of the lesson, or the degree to administration what programs are being which the course influenced student offered in their schools – thus, the school behavior. There is no routine monitoring or system may have no information about evaluation of HIV prevention programs in the those programs. schools. Each provider evaluates its own In addition, despite the complicated structure programs, and there are no consistent of DCPS' HIV/AIDS services, the DCPS standards by which to measure. Many CBOs website offers no information about the evaluate their programs through the use of services to the public other than a phone pre- and post-tests and surveys. Yet such number in their office directory for the evaluations are neither systemic (occurring in HIV/AIDS Education Program Office. As all programs on a regular basis, with data stated above, that office is no longer that can be compared across all programs) responsible for working with CBOs. A page nor objective (results are collected and listed as "Comprehensive Student Health reported by each individual program so they Program"416 says only that "this program are unlikely to be critical). coordinates health services in partnership DCPS should do a better, more systematic with the Commission of Public Health job of collecting data on the HIV/AIDS and works with students, families, staff, education programs and services provided in community-based organizations, and its schools. At present, it is highly likely that universities." No contact information or other some schools with the greatest need are details are offered. In fact, the Commission completely without HIV prevention programs. of Public Health is no longer in existence (it is now the DOH). According to the CDC, a coordinated school health program has nine components: DCPS HIV/AIDS AD health education, physical education, health services, nutrition, counseling, social HOC COMMITTEE services, healthy school environment, In November 2004, in recognition of the healthy staff, and family and community urgent need for improvement in HIV involvement.417 HIV/AIDS education and prevention and sex education, the DCPS services are an important part of a Board of Education created an Ad Hoc comprehensive health program. Yet, there Committee. This Committee included is no indication that DCPS coordinates these the Superintendent, Board of Education nine components in a meaningful way. members, representatives of the Mayor and Council, HAA officials, and representatives MONITORING, DATA from other agencies and CBOs. The COLLECTION, AND EVALUATION Committee, in which DC Appleseed also participated, met monthly to develop Limited data are available on DCPS HIV recommendations regarding the creation education programs and their impact on of comprehensive system-wide health and students. The HIV/AIDS Education Program HIV/AIDS education standards and testing provided some survey data regarding the and treatment policies for DCPS youth. The content of required health education courses Committee compared the District's health in grades 6-12. For example, 100 percent of education policies with those of other teachers in required health education courses jurisdictions and also considered national taught how HIV is transmitted and that standards for health education. abstinence is the most effective method to At the final June 2005 meeting, the avoid HIV infection. In middle schools, 87 Committee presented its recommendations percent of teachers in required health to the D.C. Board of Education. These courses taught students how to correctly recommendations addressed many of use a condom. the concerns raised in this chapter. The However, the survey data provided by the Committee recommended updating both the HIV/AIDS Education Program merely D.C. Municipal Regulations and the Board of report which topics were taught, without Education's HIV/AIDS policies, which were information on the quality of teaching, the
84 HIV/AIDS IN THE NATION'S CAPITAL last updated in 1994. The Superintendent to the School Nursing Program, HIV/AIDS and Board of Education will review the Education, and other health-related recommendations and determine the next programs. In addition, DCPS should conduct steps. The Superintendent anticipates a thorough evaluation of the functionality of formally convening a similar committee the HIV/AIDS Education Program office. of advocates and stakeholders in the fall. Expand Public Communication and Involvement. The Board of Education should establish an "Advisory Council on Student and School Health" that would include SUMMARY OF participation from DOH, HAA, CNMC, CBOs, the D.C. Council and Mayor's Office, local RECOMMENDATIONS children's health advocates, school nurses, Standards Regarding HIV/AIDS Education parents, and national experts. DCPS also in the Schools. The Board of Education and should improve communications with the DCPS should develop system-wide content public about DCPS' HIV/AIDS education standards regarding HIV/AIDS education. program. One step would be to update the The Board of Education also should review website to include detailed contact and amend the outdated D.C. Municipal information, the roles of the different offices, Regulations relating to HIV/AIDS in the the MOU policy for CBOs, and links to school system and ensure that school staff related agencies (e.g., DOH's Office of is trained regarding these regulations. Maternal and Child Health and HAA). The PUBLIC SCHOOLS HIV PREVENTION IN D.C. CHAPTER VII: Evaluation. In collaboration with CBOs, website could provide links to data and DCPS should develop standardized research, and more importantly, where to performance measures for HIV/AIDS obtain HIV testing, prevention, and care education. These performance measures services. should be used to evaluate all schools and all HIV/AIDS services provided in public schools. Data Collection. The District should establish guidelines and policies to improve CONCLUSION collection of data regarding HIV/AIDS DCPS is in the midst of overhauling its education programs and services in the curriculum standards and implementing an schools. Principals should be required to ambitious new strategic plan, but HIV report all HIV/AIDS service providers to the prevention is not receiving a great deal of appropriate DCPS administrative office, so attention from the administration. The Board that DCPS may maintain an updated list of of Education's recent efforts to focus on all HIV prevention programs in schools and HIV/AIDS is a step in the right direction, but ensure that all schools are providing DCPS needs a coordinated and sustained adequate HIV/AIDS prevention services. effort to reduce the spread of HIV among the District's youth. DCPS also needs to give Improved Coordination. DCPS needs to serious consideration to whether the current better align the responsibilities of its offices configuration of offices and responsibilities, that coordinate health policy and health as well as the distribution of resources, education. DCPS should create a coordinated can be improved. school health office that includes the liaison
ENDNOTES 390 HIV/AIDS Administration, District of Columbia Department of Health, The Ryan White Comprehensive AIDS Resources 388 The Henry J. Kaiser Family Foundation, National Survey of Emergency (CARE) Act: Title I HIV Emergency Relief Grant Program, Adolescents and Young Adults: Sexual Health Knowledge, Tables, at 13 (Oct. 2003) (2004 grant application on file with Attitudes, and Experiences 6 (2003), available at HIV/AIDS Administration). http://www.kff.org/youthhivstds/3218-index.cfm (last visited July 20, 2005) [hereinafter "National Survey of Adolescents and Young 391 Jo Anne Grunbaum et al., Youth Risk Behavior Surveillance – Adults"]. United States, 2003, MORBIDITY & MORTALITY WKLY. REP. SURVEILLANCE SUMMARIES 1, 71-76 (May 21, 2004), available at 389 Id. at 2. http://www.cdc.gov/mmwr/PDF/ss/ss5302.pdf (last visited July 20, 2005) [hereinafter "YRBS – 2003"].
DC APPLESEED CENTER 85 392 Id. 405 Interview with Children's National Medical Center staff member. 393 Id. 406 Interviews with school district officials from Broward County, Baltimore City, and Palm Beach County; interview with Centers for 394 The Alan Guttmacher Institute, U.S. Teenage Pregnancy Statistics: Disease Control and Prevention Adolescent and School Health Overall Trends, Trends by Race and Ethnicity, and State-by-State official; cf. CDC Guidelines for Effective School HIV Education, Information 8 (2004), available at http://www.agi-usa.org/pubs/ supra note 403, at 1. state_pregnancy_trends.pdf (last visited July 20, 2005). 407 Interview with District of Columbia Public Schools staff member. 395 Centers for Disease Control and Prevention, Sexually Transmitted Disease Surveillance, 2003, at 86 (Sept. 2004), available at 408 5 D.C. Mun. Regs. § 2304.1 (2005). http://www.cdc.gov/std/stats/toc2003.htm (last visited July 20, 409 Id. at § 2304.2. 2005). 410 Id. at § 2304.3. 396 Id. at 103. 411 Interview with District of Columbia Public Schools staff member. 397 Id. at 86, 92, 118. 412 CDC Guidelines for Effective School HIV Education, supra note 403, 398 D.C. Kids Count Collaborative for Children and Families, EVERY KID at 1. COUNTS IN THE DISTRICT OF COLUMBIA: ELEVENTH ANNUAL FACT BOOK 29 (2004), available at http://www.dckidscount.org/ 413 Meeting of the District of Columbia Public Schools Ad Hoc dckidscount.htm (last visited July 20, 2005). Committee (Feb. 8, 2005). 399 D.C. Kids Count Collaborative for Children and Families, EVERY KID 414 Interview with District of Columbia Public Schools staff member. COUNTS IN THE DISTRICT OF COLUMBIA: TENTH ANNUAL FACT 415 Based on interviews with District of Columbia Public Schools BOOK 30 (2003), available at http://www.dckidscount.org/ personnel, providers, Children's National Medical Center personnel, dckidscount.htm (last visited July 20, 2005). and meetings of the District of Columbia Public Schools Ad Hoc 400 State Center for Health Statistics Administration, District of Committee. Columbia State Health Profile 17 (2003), available at 416 District of Columbia Public Schools, Comprehensive School Health http://dchealth.dc.gov/services/administration_offices/schs/ Program, available at http://www.k12.dc.us/dcps/programs/ reports.shtm (last visited July 20, 2005). program5.html (last visited July 20, 2005). 401 YRBS – 2003, supra note 391, at 59-60. 417 National Center For Chronic Disease Prevention & Health 402 Id. at 63-64. Promotion, Centers for Disease Control and Prevention, Healthy Youth! Coordinated School Health Program, available at 403 Centers for Disease Control and Prevention, Guidelines for http://www.cdc.gov/HealthyYouth/CSHP/index.htm (last visited Effective School Health Education to Prevent the Spread of AIDS, July 20, 2005). MORBIDITY & MORTALITY WKLY. REP. SUPPLEMENTS 1 (Jan. 29, 1988) (revised in 2003), available at http://www.cdc.gov/ HealthyYouth/sexualbehaviors/guidelines/guidelines.htm (last visited July 22, 2005) [hereinafter "CDC Guidelines for Effective School HIV Education"]. 404 District of Columbia Public Schools, FY 2006 Operating Budget 49 (2005).
86 HIV/AIDS IN THE NATION'S CAPITAL PART 2: CHAPTER VIII HIV PREVENTION AMONG DRUG USERS
CHAPTER INFORMATION: DRUG USE AND HIV/AIDS Pharmacy Sales of Syringes Background on Drug Use The District's Syringe and HIV/AIDS Exchange Program Drug Use and HIV/AIDS in SUMMARY OF the District RECOMMENDATIONS HIV PREVENTION CONCLUSION STRATEGIES FOR DRUG USERS Community-Based Outreach Outreach Efforts in the District Substance Abuse Treatment Treatment in the District Access to Sterile Syringes Syringe Exchange Programs Syringe Exchange in the District
DC APPLESEED CENTER 87 Drug users are at increased risk DRUG USE AND for contracting HIV because they HIV/AIDS engage in high-risk drug and sexual behaviors. In the District, BACKGROUND ON DRUG USE AND HIV/AIDS injection drug use is the second Drug addiction is a complex chronic disease most common mode of characterized by compulsive, uncontrollable drug craving, seeking, and use, despite transmission of HIV among men, severe consequences.421 Even many of those and the most common mode of who seek and receive treatment often relapse.422 Many IDUs are marginalized and HIV transmission among cannot fully participate in the economic, 418 social, or cultural life of their community. women. Almost a third of new For those IDUs living with HIV/AIDS, the AIDS cases in the District can be stigmatization and marginalization are likely 423 directly traced to a shared to be greater. The process of injecting drugs and the needle, and far more cases can sharing of equipment provide many opportunities for the transmission of HIV be traced indirectly to drug use and other blood-borne viruses.424 Sharing through sexual contact.419 drug injection paraphernalia usually occurs because IDUs lack access to or cannot afford their own equipment.425 In addition, high-risk HIV prevention efforts in the District drug use behaviors and high-risk sexual targeting drug users and their sex partners behaviors often are linked, further increasing should be enhanced. Research has shown the risk of HIV and other blood-borne that the most effective approach for diseases being transmitted from person preventing the spread of HIV among drug to person. These risky sexual behaviors users is a comprehensive strategy that include unprotected sex and intercourse includes community-based outreach, drug with multiple partners.426 abuse treatment, and syringe access.420 Such Not all IDUs experience the same level of programs should be combined with testing risk.427 Research has shown that the relative and counseling for HIV and strategies to socio-economic status of IDUs has a direct prevent sexual transmission of HIV, such as influence on the degree of risky behavior in distribution of condoms and educational which the IDU engages. IDUs who initially material. have higher socio-economic status, housing, As this chapter describes in further detail, and support networks may be more able to although the District currently employs control their risks of transmission. Lower multiple interventions targeting drug users, income IDUs, those with mental health the District's efforts are inadequate. A problems, and those with unstable living coordinated, comprehensive approach is and social circumstances may have difficulty needed because no one intervention is obtaining sterile syringes and, thus, may be effective on its own. This chapter more likely to share injection equipment.428 recommends expanding substance abuse HIV prevention may not be the top concern treatment services. In addition, HAA for such persons, because they face other should ensure the provision of services to more pressing daily challenges such as complement syringe exchange programs addiction, poverty, incarceration, (SEPs), which have been demonstrated to homelessness, stigma, mental illness, be effective in reducing HIV transmission and past trauma.429 among injection drug users (IDUs). DOH also should improve collection and dissemination of data on substance abuse in the District.
88 HIV/AIDS IN THE NATION'S CAPITAL DRUG USE AND HIV/AIDS IN COMMUNITY-BASED THE DISTRICT OUTREACH In 2000, approximately 60,000 District Drug use is usually a covert activity, making residents – nearly one in 10 – were addicted it difficult to reach drug users and their sex to illicit drugs or alcohol.430 Almost 10 percent partners through traditional health and social of District residents reported illicit drug use service agencies.437 To effectively provide in 2000, which was almost double the prevention, treatment, and care services to nationwide reported drug use rate of 6.3 IDUs, it is essential to bring the services to percent for the same year.431 Among District IDUs in the settings in which they live and residents between the ages of 18 and 24, socialize.438 Outreach workers who are the rate of reported drug use was nearly 21 familiar with the drug use subcultures and percent – meaning that one in five reported local neighborhoods have been shown to be using illicit drugs within the past month.432 effective agents of behavioral change and In 2003, of those individuals admitted to referral sources to service agencies and substance abuse treatment, more than half substance abuse treatment facilities.439 reported heroin or cocaine as their drug of A typical outreach encounter involves face-to- 433 choice. face communication that is intended to assist There are an estimated 9,720 IDUs in the IDUs in changing their high-risk drug use and District.434 However, this estimate is based sexual behaviors. Outreach workers may on a survey that did not include the distribute literature on drug use, substance HPE II HIV PREVENTION AMONG DRUG USERS CHAPTER VIII: homeless, the incarcerated, or individuals abuse treatment, and HIV prevention, and in treatment facilities – populations that are they provide information on available known to have high numbers of IDUs.435 services. They also distribute condoms and Thus, the number of IDUs in the District may help IDUs obtain housing assistance or is likely to be significantly higher. mental health treatment. Outreach also HAA reports that, as of early 2005, 2,686 involves working with drug users' social of the IDUs in the District are living with networks to extend and reinforce prevention 440 AIDS.436 This is almost one-third of the messages and build risk-reduction skills. estimated IDUs in the District. A significantly greater percentage of IDUs may be HIV- OUTREACH EFFORTS IN THE DISTRICT positive, but, as discussed in Chapter III, Several District agencies and CBOs are the District's HIV data, including data involved in outreach efforts to District drug regarding IDUs, are unavailable. users. The District, through APRA, operates "Project Orion," a 34-foot mobile medical outreach unit targeting drug users.441 Project Orion is funded with a grant from SAMSHA HIV PREVENTION and is partnered with Unity Health Care, Inc. and HAA to provide targeted services to STRATEGIES FOR areas where addicts congregate. Project Orion provides primary medical care; case DRUG USERS management; substance abuse education Prevention of HIV among drug users and counseling; and HIV, hepatitis, STD, and requires a comprehensive strategy that TB testing and counseling.442 It also refers includes community-based outreach, individuals to detoxification and substance drug abuse treatment, and syringe access abuse treatment programs and the First programs. Without such a strategy, a Street Health Center, which coordinates substantial percentage of the District's extensive chronic disease screening and population is at increased risk of treatment services for dually- and triply- contracting HIV. Each of these diagnosed individuals.443 First Street is jointly components is described below. funded by HAA and APRA.444 In addition to being a partner in the operation of Project Orion, HAA provides grants to two CBOs to conduct outreach to IDUs.445 Other
DC APPLESEED CENTER 89 organizations in the District conduct privately- In 2001, D.C. Mayor Anthony Williams funded outreach to drug users. recognized the need for improved services for drug users and appointed the Mayor’s SUBSTANCE ABUSE Interagency Task Force on Substance Abuse TREATMENT Prevention, Treatment, & Control (Task Force) to recommend a citywide substance abuse For IDUs, substance abuse treatment is a strategy and budget. The Task Force found proven HIV prevention strategy. IDUs who do that the District has insufficient capacity to not enter treatment are up to six times more meet the demand for treatment services.454 likely to become infected with HIV than IDUs Although in 2002 there were an estimated who enter treatment and successfully avoid 60,000 individuals with substance abuse 446 relapse. Substance abuse treatment helps problems in the District, only 8,500 drug users reduce the number of drug individuals entered substance abuse injections and thus lower the risk of infection treatment.455 Although all substance abusers with HIV or hepatitis that might occur do not seek treatment, it is essential that 447 through unsafe injection practices. the District expand treatment capacity. Substance abuse treatment also provides the medical, psychological, and behavioral The Task Force established a strategy, support to help individuals stop using released in September 2003, which includes drugs.448 Further, because drug use impedes four goals: (1) "educate and empower District rational decision making, which can lead of Columbia residents to live healthy and to high-risk behavior, substance abuse drug-free lifestyles"; (2) "develop and maintain treatment can reduce the risk of HIV and a continuum of care that is efficient, hepatitis transmission through unprotected effective, and accessible to individuals sex.449 needing substance abuse treatment"; (3) "increase the public's safety and improve Sustance abuse treatment for IDUs is treatment access for offenders to ensure fair important not only to prevent HIV, but also and effective administration of justice in the for HIV-positive IDUs. Continued drug or District"; and (4) "encourage a coordinated alcohol abuse can severely impact an and focused regional response to the individual's general health, which can problem of substance abuse."456 To achieve accelerate the progression of HIV infection these four goals, the Task Force identified into AIDS. Chronic substance abuse also policy and program priorities and set up has been shown to decrease adherence a timeline and reporting procedures to track to medical treatment for those who are progress. HIV-positive.450 Although progress has been made, budget TREATMENT IN THE DISTRICT shortages have limited the District's ability to substantially improve substance abuse Substance abuse treatment programs treatment.457 The District's treatment differ in their approaches and components. capacity continues to be inadequate to meet They are generally divided into five major the demand for services.458 The District kinds of programs: detoxification; inpatient; should continue to expand treatment therapeutic communities; outpatient; services and periodically reevaluate capacity and methadone or buprenorphine levels. Expansion of treatment capacity will maintenance.451 require significant funding increases, but the According to the National Survey of District may be able to obtain additional Substance Abuse Treatment Services, 54 grants from SAMSHA or other sources to facilities in the District provide substance cover this critical service. abuse treatment.452 Although only one-third of these facilities reported that they provide ACCESS TO STERILE SYRINGES special programs for persons with HIV/AIDS, nearly 80 percent reported that they provide IDUs who share drugs, syringes, and other HIV/AIDS education, counseling, and injection equipment or who practice unsafe support. Only half of the facilities conduct sex while under the influence of drugs are at testing for HIV, hepatitis, TB, and STDs.453 high risk of contracting and spreading HIV and other infections.459 Thus, public health
90 HIV/AIDS IN THE NATION'S CAPITAL officials and substance abuse experts have Indeed, the theory of harm reduction is recommended programs, such as SEPs, standard practice when it comes to addiction that mitigate the adverse consequences treatment and HIV prevention. A Guide to of injection drug use.460 The most effective Primary Care of People with HIV/AIDS, SEPs also provide complementary services published by HHS, counsels: "The primary such as HIV testing, counseling, and drug care provider should routinely screen for drug treatment referrals. abuse and treat or refer for treatment as Several HIV prevention strategies are quickly as possible . . . [and] the provider available to IDUs.461 The National Institute should also counsel patients who are actively on Drug Abuse of the National Institutes using drugs not to share needles with others of Health describes these strategies in a and to take advantage of the programs that 465 "hierarchy of HIV/AIDS risk-reduction distribute clean needles." messages, beginning with the most effective behavioral changes that drug SYRINGE EXCHANGE PROGRAMS users can make: When implemented as part of a comprehensive HIV prevention strategy, z Stop using and injecting drugs. SEPs play a unique role in engaging hard- z Enter and complete drug abuse treatment, to-reach populations at high risk for HIV including relapse prevention. infection in effective prevention interventions z If you continue to inject drugs, take the and treatment. SEPs complement drug
following steps to reduce personal and abuse treatment by providing drug users with HIV PREVENTION AMONG DRUG USERS CHAPTER VIII: public health risks: a way to obtain sterile syringes at no cost and an opportunity for those individuals to – Never re-use or "share" syringes, water, dispose of used syringes. or drug preparation equipment. SEPs vary in their operation, but in addition – Use only sterile syringes obtained from to exchanging syringes, effective SEPs a reliable source (e.g., a pharmacy or a provide a variety of other services, including: syringe access program). (1) referrals to addiction treatment programs; – Always use a new, sterile syringe to (2) HIV testing and counseling, as well as prepare and inject drugs. screening for other blood-borne diseases; (3) – If possible, use sterile water to prepare referrals to other medical and social services; drugs; otherwise use clean water from (4) condom distribution and counseling; and a reliable source (e.g., fresh tap water). (5) nursing services. In addition, many SEPs typically have mobile units that venture out – Always use a new or disinfected into the community to reach IDUs who may container ("cooker") and a new filter be hard to reach by traditional means. ("cotton") to prepare drugs. A large and compelling body of scientific data – Clean the injection site with a new and literature support the efficacy of SEPs. alcohol swab before injecting drugs. The Director of the National Institutes of – Safely dispose of syringes after Health, Elias Zerhouni, reported to Congress 462 one use." in October 2004 that "the current scientific This hierarchy illustrates what has become literature supports the conclusion that SEPs known as "harm reduction" in the addiction can be an effective component of a community. The term "harm reduction" has comprehensive community-based HIV various meanings, but it generally refers to prevention effort."466 Furthermore, Zerhouni methods of reducing risks to health where reported: "A number of studies conducted elimination of risk may not be possible.463 As in the U.S. have shown that SEPs do not an addiction expert recently testified before increase drug use among participants or Congress, "harm reduction efforts are not surrounding community members and are intended to make drug use 'safe'; rather, associated with reductions in the incidence they seek to lessen the extraordinary of HIV, hepatitis B, and hepatitis C in the suffering, death, and dissolution of family drug-using population."467 and communities with which addiction is In 2004, the World Health Organization 464 associated." (WHO) issued a report that examined every
DC APPLESEED CENTER 91 existing scientific study on the effectiveness means of prevention.474 Similarly, the CDC, of sterile needles and syringe programming the National Institute on Drug Abuse, and in reducing HIV/AIDS among IDUs.468 The SAMSHA have issued HIV prevention report says: "Measured against any objective bulletins regarding IDUs that advise health standards, the evidence to support the professionals to counsel IDUs to stop using effectiveness of [SEPs] in substantially or injecting drugs, enter into substance reducing HIV must be regarded as abuse treatment, and take measures to overwhelming."469 The report also says that prevent or reduce risk through the use of "after almost two decades of extensive sterile syringes if they continue to inject research, there is still no persuasive evidence drugs.475 that [SEPs] increase the initiation, duration or frequency of illicit drug use or drug injecting" SYRINGE EXCHANGE IN THE DISTRICT and further that "there is reasonable evidence that [SEPs] can increase recruitment into PHARMACY SALES OF SYRINGES drug treatment and possibly also into primary Pharmacies can play a central role in the health care."470 effort to make clean injection equipment This recent WHO report echoes a similar one accessible to IDUs via "over the counter" issued in 2000 by U.S. Surgeon General sales or free distribution.476 However, David Satcher. The Surgeon General reviewed paraphernalia laws sometimes preclude a large body of peer-reviewed research on pharmacies from engaging in HIV prevention SEPs and stated "there is conclusive with IDUs. scientific evidence that syringe exchange The D.C. Code definition of "paraphernalia" programs, as part of a comprehensive HIV includes "[h]ypodermic syringes, needles, prevention strategy, are an effective public and other objects used, intended for use, health intervention that reduces the or designed for use in parenterally injecting transmission of HIV and does not encourage a controlled substance into the human the use of illegal drugs."471 After reviewing all body."477 It currently is unlawful for any of the research to date, the Surgeon person to use, to possess with intent to use, General's Report concluded that properly- to deliver or sell, or possess with intent to implemented SEPs lead to: "[1] a decrease in deliver or sell drug paraphernalia if it is to be new HIV seroconversions; [2] an increase in used, or if one reasonably should know that the numbers of IDUs referred to and retained it will be used, to introduce an illegal in substance abuse treatments; and [3] well substance into the human body.478 Thus, a documented opportunities for multiple pharmacist in the District may not sell or prevention services and referral and entry distribute sterile syringes to individuals who to medical care."472 The report furthermore the pharmacist reasonably believes will use concluded that SEPs do not increase the the syringe for illegal purposes. There is one illegal use of drugs among those individuals noteworthy exception to this section of the participating in the programs and may in District's paraphernalia law: the D.C. Code fact decrease injection frequency.473 authorizes the Mayor to establish SEPs, Finally, numerous organizations have formally "which may provide clean hypodermic recognized the significance of SEPs and the needles and syringes to injecting drug importance of access to sterile syringes as a users."479 People participating in SEPs can means of preventing the transmission of legally possess and transfer syringes as long blood-borne diseases such as HIV. In 1999, as they do so as part of the program.480 the American Medical Association, the In order to increase access to sterile injection American Pharmaceutical Association, the equipment, the District should consider Association of State and Territorial Health amending its paraphernalia laws to make Officials, the National Association of Boards clean syringes more accessible through of Pharmacy, and the National Alliance of pharmacies. A growing number of states, State and Territorial AIDS Directors including Oregon, Wisconsin, Connecticut, collectively issued a "Dear Colleague" letter Maine, Minnesota, New Hampshire, New urging state leaders in pharmacy, public York, Rhode Island, New Mexico, and health, and medicine to coordinate efforts to address access to sterile syringes as a
92 HIV/AIDS IN THE NATION'S CAPITAL California, have removed barriers to distribution of sterile syringes, which, as purchasing syringes at pharmacies.481 mentioned, is needed in the District. Therefore, HAA should fund supplementary THE DISTRICT'S SYRINGE EXCHANGE services provided by any SEP. PROGRAM Once Congress enacted the prohibition on PreventionWorks! is the District's only District funding for the distribution of clean authorized SEP. According to their website, syringes, the general perception in the the mission of PreventionWorks! is "to curb community was that the prohibition put in the spread of HIV and other blood-borne jeopardy the local and federal funding for any diseases among injecting and other drug organization operating or associated with an users, their sexual partners, and newborn SEP. As noted, this perception is false. children." The program does this by providing Therefore, District officials should ensure syringe exchange services, as well as that employees of relevant District agencies drug treatment referrals, HIV testing and and CBOs understand that collaboration and counseling, safe sex materials and co-location with SEPs is permissible. For information, viral hepatitis outreach, support example, a representative of an organization groups, overdose prevention training, food, that provides HIV testing and counseling and clothing. could provide those services alongside the PreventionWorks!, however, is able to fulfill PreventionWorks! outreach vehicle. HAA only a small portion of the District's need for should facilitate such collaboration and
HIV prevention services among injection drug co-location between SEPs and District HIV PREVENTION AMONG DRUG USERS CHAPTER VIII: users. In fiscal year 2003, PreventionWorks! agencies and CBOs to strengthen reached approximately 3,200 of the District's comprehensive HIV prevention services estimated 9,720 IDUs.482 provided to IDUs in district. Congress has barred the District from using federal or local public funds to support the distribution of sterile injection equipment. Therefore, only private funds may be used to SUMMARY OF support this activity. Research has shown RECOMMENDATIONS that SEPs receiving government funding are more effective at reducing HIV transmission Data Collection and Dissemination. DOH and referring clients to drug treatment should gather and disseminate data on the programs than SEPs that do not receive number and characteristics of IDUs and government funding.483 This is because SEPs substance abusers in the District in order to that receive government funding are far more target interventions. likely to distribute enough sterile syringes Substance Abuse Treatment. The District to meet demand and to provide multiple has insufficient capacity to meet the demand complementary services necessary for a for treatment services. The District should comprehensive HIV prevention network demonstrate a commitment to increasing the for IDUs.484 availability of substance abuse treatment Significantly, the congressional prohibition programs. does not preclude federal or local public Access to Sterile Syringes. Given the funding for complementary services that do overwhelming evidence that SEPs reduce not entail the distribution of syringes. Thus, the incidence of HIV without increasing PreventionWorks! is eligible for public illegal drug use, the District government and funding for services that do not involve the advocates should continue efforts to distribution of sterile syringes. Public funding persuade Congress to lift the ban on the would allow expansion of complementary use of local funds for syringe exchange services that would likely increase the programs. In the meantime, HAA should program's effectiveness in preventing the fund complementary services provided by spread of HIV and reducing drug use. Public the privately-funded syringe exchange funding for complementary services would program. In addition, HAA should encourage allow PreventionWorks! to allocate a larger community-based organizations that provide percentage of its private funds to additional complementary HIV/AIDS services to
DC APPLESEED CENTER 93 collaborate and co-locate with the syringe District provides HIV prevention services for exchange program – thereby enhancing HIV drug users, two of the central components prevention among the District's drug users. of a comprehensive strategy – substance Furthermore, the District should consider abuse treatment and access to sterile amending its paraphernalia laws to make syringes – are inadequate. HAA should clean syringes more accessible through create a comprehensive HIV prevention pharmacies. strategy for all drug users, and District leaders should facilitate implementation of the strategy with all necessary resources. The HIV/AIDS epidemic in this city will CONCLUSION continue among drug users and their sex partners until a comprehensive strategy is HIV prevention with drug users requires a created and executed. comprehensive strategy with several components. The District currently has no such comprehensive strategy. Although the
ENDNOTES 436 2005 Epi Supplement, supra note 34, at 42-46. 418 2003-2004 HIV Prevention Plan, supra note 53, at 2.46. 437 Principles of HIV Prevention in Drug-Using Populations, supra note 420, at 3. 419 2005 Epi Supplement, supra note 34, at 23-29. 438 Preventing Blood-borne Infections among IDUs, supra note 421, at 420 National Institute on Drug Abuse, U.S. Department of Health and A3. Human Services, Principles of HIV Prevention in Drug-Using Populations (NIH Pub. No. 02-4733) 16-17 (Mar. 2002), available at 439 Principles of HIV Prevention in Drug-Using Populations, supra note http://www.nida.nih.gov/PDF/POHP.pdf (last visited July 19, 2005). 420 at 3. 421 Academy for Educational Development, A Comprehensive 440 Preventing Blood-borne Infections among IDUs, supra note 421, at Approach: Preventing Blood-Borne Infections among Injection Drug A3. Users A2 (Dec. 2000), available at http://thebody.com/cdc/pdfs/ 441 Addiction Prevention and Recovery Administration, District of comprehensive-approach.pdf (last visited July 19, 2005) Columbia Department of Health, Project Orion, available at [hereinafter "Preventing Blood-Borne Infections among IDUs"]. http://www.doh.dc.gov/doh/cwp/view,a,1374,q,576012,dohNav_GI 422 Center for AIDS Prevention Studies, University of California San D,1803.asp (last visited July 20, 2005). Francisco, What Are Injection Drug Users (IDU) HIV Prevention 442 Id. Needs? CAPS FACT SHEET 51E 1 (Sept. 2003), available at http://www.caps.ucsf.edu/pdfs/IDUFS.pdf (last visited July 19, 443 Interview with District of Columbia government official. 2005) [hereinafter "IDU HIV Prevention Needs"]. 444 Id. 423 Preventing Blood-Borne Infections among IDUs, supra note 421, 445 Id. at 13. 446 National Institute on Drug Abuse, U.S. Department of Health and 424 Id. Academy for Educational Development, Access to Sterile Human Services, Principles of Drug Addiction Treatment: A Syringes (Jan. 2000), available at http://www.cdc.gov/idu/ Research-based Guide (NIH Pub. No. 99-4180) 20 (Oct. 1999), facts/aed_idu_acc.pdf (last visited July 19, 2005). available at http://www.nida.nih.gov/pdf/podat/podat.pdf (last 425 IDU HIV Prevention Needs, supra note 422, at 1. visited July 20, 2005). 426 Preventing Blood-Borne Infections among IDUs, supra note 421, 447 Preventing Blood-borne Infections among IDUs, supra note 421, at 1. at 27. 427 Id. at 7-8. 448 Id. at A2. 428 Id. at 8. 449 Id. 429 S. Galea & D. Vlahov, Social Determinants and the Health of Drug 450 Substance Abuse and HIV, supra note 333, at 9. Users: Socioeconomic Status, Homelessness, and Incarceration, 451 Preventing Blood-borne Infections among IDUs, supra note 421, PUB. HEALTH REP. [Suppl. 1] S135-S145 (May/June 2002). at A2. 430 D.C. Substance Abuse Strategy, supra note 52, at 1-1. 452 National Survey of Substance Abuse Treatment Services, U.S. 431 Id. at 2-3. Department of Health and Human Services, State Profile for District of Columbia 2003, available at 432 Id. at 2-2. http://wwwdasis.samhsa.gov/webt/tedsweb/tab_year.choose_yea 433 D. Wright & N. Sathe, State Estimates of Substance Use for the r_state_profile?t_state=DC (last visited July 20, 2005). 2002-2003 National Surveys on Drug Use and Health (DHHS Pub. 453 Id. No. SMA 05-3989, NSDUH Series H-26). Rockville, MD: Substance Abuse and Mental Health Services Administration, Office of 454 D.C. Substance Abuse Strategy, supra note 52, at 2-6. Applied Studies, available at http://oas.samhsa.gov/2k3State/ 455 Id. toc.htm (last visited July 19, 2005). 456 Id. at 4-2 through 4-4. 434 2003-2004 HIV Prevention Plan, supra note 53, at 2.46. 457 Interview with District of Columbia government official. 435 D.C. Substance Abuse Strategy, supra note 52, at 5-14. 458 Id.
94 HIV/AIDS IN THE NATION'S CAPITAL CHAPTER VIII: HIV PREVENTION AMONG DRUG USERS 95 (last (last (last available , available at note 421, (last visited July note 53, at 2.46. supra , available at State Approaches to (last visited July 21, supra , .htm 6 (Dec. 2, 2003), .org/references/Satcher00.html available at Public Funding of US Syringe Exchange .com/amfar/pdfs/syringe_access.pdf Creating a New Future in Washington, D.C.: .thebody http://www/cdc.gov/idu/pubs/hiv_prev_acc.htm .preventionworksdc.org/fiveyears.pdf .dogwoodcenter .cdc.gov/idu/pubs/hiv_prev (Mar. 17, 2000), 17, (Mar. 2003-2004 HIV Prevention Plan , 81 J. URBAN HEALTH 118 (Mar. 2004). 118 (Mar. , 81 J. URBAN HEALTH Joint Letter from E. Ratcliffe Anderson, Jr., Executive Vice Jr., Joint Letter from E. Ratcliffe Anderson, National Center for Director, Joint Letter from Helene D. Gayle, American Foundation for AIDS Research, http://www . . . . . at §§ 48-1103(a) and (b). . at § 48-1103.01(a). . at § 48-1103.01(d). April 1998 Expanded Access to Sterile Syringes Through Pharmacies PreventionWorks! Turns Five Programs Programs: An Analysis of the Scientific Research Completed Since at 21, 2005); 2005). President, American Medical Association et al. (Oct. 1999), President, American Medical Association (May 9, 1997), STD, and TB Prevention, CDC, et al. HIV, http://www Id Id Evidence-Based Findings on the Efficacy of Syringehttp://www Exchange Id Id See available at visited July 21, 2005). See http://www Preventing Blood-Borne Infections among IDUs Id Id Id See visited July 21, 2005). visited July 22, 2005). visited July 22, at A7. 483 Don C. Des Jarlais et al., 471 and Surgeon General, Assistant Secretary for Health David Satcher, 473 474 479 480 481 484 476 470 475 482 PreventionWorks!, 472 477 CODE § 48-1101(k) (2001). D.C. 478 note available supra supra (last visited , (last visited .pdf .org/binary- .amfar Harm Reduction Fact Syringe Exchange Programs .cdc.gov/idu/facts/ available at http://www (last visited July 21, 2005). Effectiveness of Sterile Needles and http://www .who.int/hiv/pub/prev_care/en/ available at (last visited July 20, 2005). (last visited July (last visited July 20, 2005). available at http://www .htm .democrats.reform.house.gov/Documents/20050113120 AR_PPOLICY_BINARY/binary_file/14.pdf (Feb. 2005), (World Health Organization, Geneva, Switzerland) (2004), Health Organization, Geneva, Switzerland) (World http://reform.house.gov/UploadedFiles/ . at 28. . at 3. . . Users Sheet Syringe Programming in Reducing HIV/AIDS among Injecting Drug at available at effectivenesssterileneedle.pdf Id Health, to the Honorable Henry A. Waxman, Ranking Minority Health, to the Honorable Henry A. Waxman, Committee on Government Reform, U.S. House of Member, Representatives, 1-2 (Oct. 7, 2004), http://www 703-78979.pdf Id Robert%20G.%20Newman,%20MD%20testimony note 311, at 105, 111. data/AMF 1 (Jan. 2000), aed_idu_syr Id Principles of HIV Prevention in Drug-UsingId Populations July 20, 2005). 420, at 13. Rothschild Chemical Dependency Institute of Beth Israel Medical Rothschild Chemical Dependency Epidemiology and Population Health NYC Professor, Center, Behavioral Sciences Albert Einstein Psychiatry and Professor, of Representatives Government College of Medicine, U.S. House and Human Justice, Drug Policy, Reform Subcommittee on Criminal or Harm Maintenance: Is Resources Hearing on Harm Reduction Abuse? (Feb. 16, 2005), There Such A Thing as Safe Drug July 20, 2005). 467 468 Cooney, & Annie Alex Wodak 469 461 463 Foundation for AIDS Research, American DC APPLESEED CENTER 459 Development, Educational Academy for 460 466 National Institutes of Director, Letter from Elias A. Zerhouni, M.D., 465 WITH HIV/AIDS, A GUIDE TO PRIMARY CARE OF PEOPLE 462 464 de The Baron Edmond of Robert G. Newman, Director, Testimony
PART 2: CHAPTER IX HIV/AIDS AMONG THE INCARCERATED
CHAPTER INFORMATION: HIV/AIDS AMONG THE HEALTH AND HIV/AIDS ADAP Funding REENTRY ISSUES FOR INCARCERATED SERVICES AT THE Federal Supply Schedule EX-OFFENDERS D.C. JAIL AND THE Purchases DETENTION FACILITIES IN Services by Local Vendors in CORRECTIONAL TREATMENT Other Alternatives the District THE DISTRICT FACILITY The DOC and the Revitalization DISCHARGE PLANNING FOR Services by CSOSA in the District HIV Prevention Services Act D.C. INMATES IN FEDERAL SUMMARY OF The D.C. Jail HIV Testing and Counseling FACILITIES RECOMMENDATIONS HIV/AIDS Education The Correctional Treatment Discharge Planning by Our CONCLUSION Facility Substance Abuse Treatment Place D.C. THE D.C. INMATE Condom Distribution Discharge Planning by the HIV/AIDS Treatment Court Services Offender POPULATION Supervision Agency Discharge Planning Provision of HIV/AIDS Medication at Discharge
DC APPLESEED CENTER 97 The HIV/AIDS epidemic facilities in the District upon release from custody. In addition, expanded discharge disproportionately impacts the planning services for District inmates in incarcerated.485 The higher AIDS federal facilities are recommended. rates among the incarcerated suggest that the population is HIV/AIDS AMONG engaging in risk behaviors prior THE INCARCERATED to or during incarceration, and In 2001, 1.9 percent of the prison population they have an increased need for in the United States was estimated to be HIV-positive, as compared to less than 0.4 HIV education and prevention percent of the country's total population.486 It services. The incarcerated are is very difficult to determine the number of District inmates that are living with HIV/AIDS. isolated from the mainstream The District's 2004 Epidemiological Profile indicates that there were 338 male and 50 system of prevention and care female District inmates living with AIDS as of while they await trial or serve December 31, 2002.487 The Epi Profile does not indicate whether these inmates are at their sentences, which presents local detention facilities or in the federal an opportunity for targeted system. More importantly, HAA does not have meaningful current or past data or a prevention and care services mechanism in place to collect data about the prior to their release back into prevalence of HIV and AIDS among the inmates at detention facilities in the District. the community. In early 2005, medical staff at the D.C. Jail reported the recent number of inmates at the detention facilities in the District who are This chapter describes the HIV/AIDS services taking antiretroviral medication ranges from for the incarcerated in detention facilities in about 200 to 235 (about 7 percent of the the District, as well as reentry services for population).488 Data on HIV/AIDS among the ex-offenders returning to the community. incarcerated should be collected, analyzed, Recommendations include improved and disseminated regularly. HAA should collection and dissemination of data on regularly conduct a facility-wide anonymous HIV/AIDS incidence and prevalence among HIV prevalence study to ascertain the the incarcerated, better coordination and severity of the problem in the District's reduction in the number of HIV/AIDS service incarcerated population. Such data are providers, implementation of rapid testing, important for projecting the need for medical expansion of substance abuse treatment, services and discharge planning. and provision of a 30-day supply of medication to all inmates at detention
Quick Facts: z D.C. inmates in D.C. facilities, including halfway houses (average during first half FY2005): 3,490 z Average length of stay in D.C. facilities: 231 days z D.C. inmates in federal facilities (Dec. 2001): 6,930 z D.C. inmates living with AIDS as of December 31, 2002: 388 total (338 men and 50 women)
Based on statistics from the D.C. Department of Corrections, available at http://doc.dc.gov/doc/frames.asp?doc=/doc/lib/doc/populationstats/ DC_Department_of_Corrections_Facts_and_Figures_June_05.pdf (last visited July 24, 2005); Paige M. Harrison & Jennifer Karberg, Prison and Jail Inmates at Midyear 2002, BUREAU OF JUSTICE STATISTICS BULLETIN 3 (Apr. 2003), available at http://www.ojp.usdoj.gov/bjs/pub/pdf/pjim02.pdf (last visited July 24, 2005); District of Columbia Department of Health, The HIV/AIDS Epidemiologic Profile for the District ofColumbia 36 (Dec. 2003).
98 HIV/AIDS IN THE NATION'S CAPITAL present CTF reportedly functions as an DETENTION "overflow" facility for the D.C. Jail.499 According to D.C. Jail and CTF staff, there is FACILITIES IN no difference in the makeup of the two THE DISTRICT inmate populations, and inmates are shifted back and forth between the two facilities as THE DOC AND THE space requirements dictate.500 The CTF houses a handicapped unit and an inpatient REVITALIZATION ACT medical unit. In 2005, the CTF's average Historically, the DOC functioned as both a daily census ranged from 1,081 to 1,218.501 local and state correctional system.489 The Central Detention Facility (D.C. Jail) and the adjacent Correctional Treatment Facility (CTF), which are further described below, detained THE D.C. INMATE primarily pretrial and presentence inmates and probation and parole violators.490 The POPULATION majority of convicted felons were housed at The average length of stay of an inmate in 491 the Lorton prison complex in Virginia. In DOC custody is about 231 days, although the 1995, the Lorton facilities housed more than majority of inmates stay less than 30 days.502 492 7,800 prisoners. Of the District inmates, 88 percent are male In the late 1990s, the DOC was reorganized and 12 percent are female.503 The racial pursuant to the National Capital Revitalization breakdown is 92 percent African American, HIV/AIDS AMONG THE INCARCERATEDCHAPTER IX: and Self-Government Improvement Act of 4 percent Latino, 3 percent White, and 1 1997 (Revitalization Act).493 Pursuant to the percent other.504 Revitalization Act, the District closed the Lorton facilities and transferred custody of nearly 8,000 felons convicted in the District to the Federal Bureau of Prisons (BOP) by HEALTH AND the end of 2001.494 As of April 1, 2002, District inmates were scattered among 75 HIV/AIDS SERVICES different prisons across the country.495 AT THE D.C. JAIL AND THE D.C. JAIL THE CORRECTIONAL At present, the DOC's responsibilities are limited primarily to operating the D.C. Jail. TREATMENT FACILITY The D.C. Jail houses inmates who are Currently, the Center for Correctional Health awaiting trial, have been convicted of a and Policy Studies, Inc. (CCHPS), the DOC's misdemeanor offense, or are awaiting contractor, provides medical and mental transfer to the BOP after conviction of a health services at the D.C. Jail and CTF felony.496 In 2005, the average daily census and conducts inmate health screening at levels at the D.C. Jail ranged from 2,148 to intake.505 2,339.497 Medical services are provided by To provide HIV/AIDS counseling, testing, a private contractor selected through a prevention, education, and discharge competitive bidding process. planning to the inmate population, HAA has issued grants to a number of vendors. In THE CORRECTIONAL addition to a HAA staff member assigned to TREATMENT FACILITY the D.C. Jail, four HAA-contracted vendors provide HIV/AIDS education, counseling, and In May 1992, the DOC opened the CTF discharge planning to incarcerated or adjacent to the D.C Jail. In March 1997, the formerly incarcerated individuals. Before DOC entered into a 20-year contract with examining the various services provided, it the Corrections Corporation of America for is necessary to give a brief overview of the the operation and management of CTF.498 vendors involved. Originally designed to serve specialized confinement and health care needs, at
DC APPLESEED CENTER 99 District of Columbia Department of Corrections, D.C. Department of Corrections Facts and Figures 11 (June 2005)
The following providers conduct a number of to address the needs of juveniles and HIV prevention activities in the D.C. Jail and women,513 but it is unclear whether the the CTF: organization's services are aimed at those groups. Miracle Hands also provides z HAA assigns a public health advisor to the D.C. Jail, who reportedly spends about 90 supportive housing and a day program to percent of his time at the D.C. Jail and is HIV-positive ex-offenders, and discharge 514 primarily responsible for education, planning at a halfway house. counseling and testing, and coordination Discerning the identities and precise roles of of other vendors.506 organizations involved in providing HIV/AIDS services at the D.C. Jail and the CTF proved z Family and Medical Counseling Services, Inc. (FMCS) has an HIV/AIDS very difficult. Even high-level officials at the prevention, education, testing, counseling, DOC were unaware of the number or names and discharge planning program called of all the organizations that were involved in "Project Ujima" at both the D.C. Jail and providing such services to inmates, let alone the CTF.507 FMCS appears to have the how various organizations receive referrals largest presence at the D.C. Jail. or interact with one another. Of the four HAA grantees, FMCS and z Us Helping Us (UHU) has a grant from HAA to provide discharge planning Miracle Hands currently have access to 515 services to District inmates, both at the inmates at the D.C. Jail. FMCS is the only D.C. Jail and in the federal prisons.508 vendor providing services to inmates in the UHU targets MSM and transgenders.509 custody of the CTF, and no other vendors have provided services there in the past. z Our Place DC provides discharge planning At least one vendor has reported repeatedly and HIV prevention services for seeking access to the D.C. Jail without incarcerated D.C. women through a peer success, and another has found it difficult 510 education system. Its work is conducted to obtain access to inmates at the CTF. primarily in federal correctional institutions that house District inmates.511 The confusion about who is supposed to have access to inmates under HAA grants z Miracle Hands conducts peer education and the lack of oversight of their activities training and HIV/AIDS education at the may result in duplicative services or in some 512 D.C. Jail. HAA expected Miracle Hands subgroups not receiving adequate attention
100 HIV/AIDS IN THE NATION'S CAPITAL because of a lack of clear delineation of HIV PREVENTION SERVICES responsibility. The number of vendors appears excessive, particularly given the HIV TESTING AND COUNSELING difficulty in ascertaining which vendors were CCHPS conducts a thorough physical authorized to have access to the population examination of all District inmates, including inside the D.C. Jail and the CTF. Unless a chest X-ray and some routine STD testing DOC knows more about the vendors and for each inmate at intake. Approximately 60 their purpose, access issues will continue. to 80 new inmates arrive at the D.C. Jail HAA and the DOC should consider each night.520 According to the D.C. Jail's establishing or permitting one vendor to treatment protocol, "[a]ll DOC inmates [are] provide or coordinate both medical services evaluated for history, signs, and symptoms and all HIV/AIDS services throughout the of HIV infection during intake and periodic D.C. correctional system. By having a single sick call evaluations."521 However, HIV testing vendor, efforts would not be duplicated at the D.C. Jail is conducted on a voluntary and the whole population would be better basis. served. At a minimum, the DOC and HAA D.C. Jail inmates may initiate HIV testing in should reduce the number of providers as several ways. First, inmates may request an well as increase interagency communication. HIV test during the health assessment Other jurisdictions have successfully component of their initial intake at the D.C. streamlined HIV/AIDS services in their jails Jail.522 During the intake process, CCHPS under one vendor or the health department. staff informs all inmates of the available HIV/AIDS AMONG THE INCARCERATEDCHAPTER IX: For example, at the San Francisco County testing resources verbally and through a Jail, all medical services, including HIV/AIDS specialized pamphlet.523 Second, inmates services, are provided to inmates by the may request an HIV test at any time by Department of Health with collaboration completing a sick call form.524 Completed from physicians from the University of sick call forms are collected from the housing California – San Francisco.516 At the San units on a daily basis and can be accessed Diego County Jail, the Sheriff's department only by authorized health care personnel.525 works in partnership with university Third, inmates may request an HIV test from physicians to provide medical services, with one of the HIV counselors working in the nurses in the medical unit conducting HIV D.C. Jail.526 counseling and testing and a single CBO Inmates who request an HIV test are providing HIV/AIDS patient management assigned within 48 hours to an HIV counselor and discharge planning services.517 provided by HAA or FMCS.527 Although there FMCS was the sole provider under the is no formal protocol for dividing requests HAA contract until 2002. In 2002, HAA between counselors, staff at CCHPS make increased the number of vendors, reportedly assignments based on caseload demands.528 to improve outreach to special populations Once an inmate is assigned to an HIV within the D.C. Jail, such as transgenders, counselor, the inmate receives both pre-test MSM, and women. Particularly in the case and post-test counseling services.529 of transgenders and MSM, however, this If an inmate's test is negative, the post-test rationale is dubious because many inmates counseling will involve discussing that are hesitant to identify as transgender person's risk factors, reiterating the or MSM for fear of violence or other principles of HIV prevention, and repercussions in the criminal justice setting. recommending testing every six months.530 Having multiple providers for different If an inmate's HIV test is positive, a range populations presents a practical problem of post-test counseling services is available. of revealing private information about CCHPS mental health professionals are individuals based on assignment to available to HIV-positive inmates, as are provider.518 A single vendor providing counselors and HIV-positive peer support services for a variety of diseases and groups.531 Reportedly, if an inmate is populations may reduce confidentiality released from the D.C. Jail before his or her concerns and costs.519 test results are received, efforts are made to locate and contact the inmate.532
DC APPLESEED CENTER 101 At present, FMCS estimates that it performs certificate and then can participate in between 100 and 200 HIV tests per month educating their peers in subsequent courses. at the D.C. Jail, but official data on the total Peer educators also participate in support number of HIV tests conducted at the D.C. groups for HIV-positive inmates, which Jail was unavailable.533 Currently, rapid discuss issues such as transmission, testing is not being used at the D.C. Jail or opportunistic infections, and the differences the CTF. The D.C. Jail medical staff and HAA between HIV and AIDS. In addition, Miracle grantees should continue to offer testing to Hands conducts six-week peer education the inmate population, but should develop a training and HIV/AIDS education classes at plan to implement rapid testing. With the the D.C. Jail. FMCS counselors and HAA's rapid turnover at the D.C. Jail and the CTF, public health advisor occasionally make visits it is particularly important for inmates to to cellblocks at the D.C. Jail to discuss HIV receive their test results as quickly as prevention strategies.535 possible. At the CTF, FMCS provides an orientation There has been discussion of mandating HIV to all inmates, which includes information on testing of inmates at detention facilities in infectious diseases, including HIV.536 FMCS the District. In interviews with DC Appleseed provides group education at the CTF, but Project Team members, numerous there currently is no peer education program correctional medicine experts throughout in the facility.537 the country voiced strong opposition to this The basic training for new employees at the approach because of inmate privacy and D.C. Jail includes a four-hour educational safety concerns. In addition, studies show segment on health precautions, including that jails should focus on counseling, prevention of HIV, TB, and Hepatitis C. Such education, and voluntary testing as opposed programs should be continued. to mandatory testing.534 In order to increase the percentage of inmates tested, the DOC SUBSTANCE ABUSE TREATMENT and HAA should develop a joint strategy for As explained in Chapters I and VIII, the implementation of routine rapid testing substance abuse is a common mode of at detention facilities in the District. The cost HIV transmission, and substance abuse implications of routine and rapid testing are treatment is a critical prevention mechanism. discussed in Chapter V. The availability of treatment is particularly HIV/AIDS EDUCATION important for the incarcerated, because substance abuse is so common among All inmate HIV/AIDS education at the D.C. offenders. The District's Pretrial Services Jail and the CTF is voluntary. For the most Agency estimated that in 1999, 69 percent part, health practitioners at the D.C. Jail of arrestees tested positive for an illegal employ HIV/AIDS peer education, which they substance such as cocaine, marijuana, have found particularly effective. FMCS opiates, methamphetamines, or PCP at the periodically conducts an "HIV 101" course time of arrest, with 25 percent of arrestees consisting of five to eight sessions. Inmates testing positive for multiple drugs.538 Of who complete the course receive a defendants arrested for burglary, 100 percent tested positive for some drug, along with 85 The Relevance of Substance Abuse percent of those arrested for larceny or theft and more than 90 percent of those arrested The interplay between substance abuse and the criminal justice for drug possession.539 Over the course of system is undeniable. It is estimated that 75 to 80 percent of 1999, 46 percent of all defendants tested prisoners "may be characterized as alcohol- or drug-involved positive for cocaine, opiates, or PCP at the offenders." In D.C., many ex-offenders participate in substance time of arrest.540 In addition, almost 70 abuse treatment programs, both residential programs such as percent of defendants and offenders under those offered at Safe Haven, and day treatment, such as that the supervision of the Court Services available at the Whitman Walker Clinic's Max Robinson Center. Offender Supervision Agency (CSOSA) (many of whom pass through the custody
Bureau of Justice Statistics, Substance Abuse and Treatment, State and Federal Prisoners, 1997, at 1, of the D.C. Jail or the CTF) have a history available at http://www.ojp.usdoj.gov/bjs/pub/pdf/satsfp97.pdf (last visited July 24, 2005). of substance abuse.541
102 HIV/AIDS IN THE NATION'S CAPITAL Given the prevalence of substance abuse The Montgomery County Correctional among arrestees and defendants, providing Facility, the Arlington County Detention sufficient and adequate treatment to inmates Facility, the Fairfax County Adult Detention at the D.C. Jail should be a priority. The D.C. Center, and the Prince George's County Jail currently provides a very limited amount Corrections Center all house jail-based of substance abuse treatment. The D.C. Jail treatment programs.551 Most of the offers Safety Net, a 28-day treatment programs permit both court-ordered and preparation program with the capacity for volunteer enrollment. These programs are 80 male inmates and 20 female inmates, designed as therapeutic communities that to prepare participants for future substance separate the enrolled inmates from the abuse treatment.542 The DOC recently general population in order to provide received a Department of Justice grant to intensive, continuous substance abuse provide a six- to 12-month Residential treatment and counseling services. In Substance Abuse Treatment (RSAT) program addition to providing treatment to inmates at the D.C. Jail.543 Forty men and 20 while in jail, there is a focus on reentry and women will participate.544 It is aimed at aftercare services that connect released misdemeanants and is available on a court- inmates to treatment resources in the ordered as well as a voluntary basis.545 community and monitor their progress, CTF provides a substance abuse education sometimes for several years. program for 30 males and 30 females.546 As explained in Chapter VIII, substance Substance Abuse Treatment HPE X HIV/AIDS AMONG THE INCARCERATEDCHAPTER IX: abuse treatment is a vital HIV prevention Number of Beds Max. Percentage Approximate for Substance of Population in intervention. Further, studies in D.C. have Jurisdiction Jail Population Abuse Treatment Treatment shown that "involvement in drug treatment Prince George's County 1,200 inmates555 120 beds556 10 percent programs with regular drug testing and Montgomery County 650 inmates557 64 beds558 9.8 percent immediate sanctions for violations resulted in 559 560 a 70 percent reduction in recidivism in the Arlington County 600 inmates 36 beds 6 percent 12 months following completion of the Fairfax County 1,200 inmates561 55 beds562 4.6 percent programs."547 For these reasons and because D.C. Jail and CTF 3,490 inmates563 60 beds 1.8 percent of the high rate of drug use by inmates, the DOC should expand the number of substance abuse treatment slots at its The general model for intensive substance detention facilities. DOC should explore the abuse treatment programs for the possibility of securing additional funding incarcerated was developed for prisons and from SAMHSA and other sources to cover requires a long-term commitment that the cost of expanding the substance abuse ranges from three months to one year or treatment programs at the D.C. Jail. more. This model excludes the more Many neighboring jurisdictions operate jail- transient jail population, who may only stay based substance abuse treatment programs in jail for a month or less. To address this that can serve as good models for the issue, both Prince George's County and District. Funding for these programs is mainly Arlington County have short-term treatment local, but some federal funding is available options that make intensive drug treatment through the Washington-Baltimore High services accessible to pre-trial inmates Intensity Drug Trafficking Area (HIDTA) and inmates serving one- or two-month 552 Treatment/Criminal Justice Initiative.548 sentences. Montgomery County's Jail HIDTA provides funding for substance Addiction Services program also develops abuse treatment services in 12 jurisdictions alternatives to incarceration for qualifying surrounding the District and Baltimore, inmates, such as referrals to inpatient 553 including some treatment services in the treatment programs outside of jail. District, but the District does not use that Unfortunately, the demand for all of these funding for jail-based treatment programs.549 jail-based treatment options is greater than Unfortunately, HIDTA currently does not have the program capacity, and all four counties 554 any funding available to expand existing have waiting lists. programs or fund new programs.550 The D.C. Jail is lagging behind nearby jurisdictions in terms of the capacity of its
DC APPLESEED CENTER 103 substance abuse treatment programs. This inmates who report being on antiretroviral is especially worrisome because the medications who do not recall the names District's high substance abuse rate and and doses are referred to the sick call HIV/AIDS prevalence may accelerate the clinician for verification of diagnosis and spread of HIV/AIDS among drug users and treatment.573 Fourth, inmates diagnosed with the incarcerated. The CDC has called for HIV during their stay at the D.C. Jail receive increased substance abuse treatment in a thorough medical evaluation, conducted by jails and prisons as a means to combat the the part-time infectious disease doctor, to spread of HIV/AIDS.564 Given the high determine the appropriate treatment number of inmates with substance abuse regimen.574 The DC Appleseed Project Team problems and the link between substance did not evaluate CCHPS’ adherence to these abuse and HIV transmission, the DOC should protocols, but close monitoring of adherence take immediate steps to increase the to medication regimens is critical to capacity of its substance abuse treatment preventing the development of drug programs. resistance among inmates. Such monitoring is particularly necessary when inmates are CONDOM DISTRIBUTION transferred between facilities. The District has a progressive condom distribution policy that should be continued. DISCHARGE PLANNING Various experts indicate that the D.C. Jail is Discharge planning prepares inmates for one of the few jails that distributes condoms release and reintegration into the community. through official channels.565 Official DOC The process is particularly important for policy prohibits sexual contact between inmates with chronic diseases because, with inmates, but medical staff and HAA-funded proper discharge planning, they can leave jail providers are permitted to provide condoms with connections to health care providers at the D.C. Jail on request.566 The CTF does and receive care as soon as necessary after not permit condom distribution.567 Research release. On the other hand, without of condom distribution in jails in other discharge planning, newly released inmates jurisdictions shows varying approaches to can find themselves with no health care the issue, with some permitting but most provider and no information about their prohibiting such distribution.568 The condom medical records and medication needs. distribution program at the D.C. Jail should Discharge planning for inmates with continue and should be expanded to provide HIV/AIDS occurs through CCHPS and FMCS. condoms to both male and female inmates at discharge. The DOC should obtain In general, FMCS coordinates with CCHPS condoms from HAA through the HAA on the discharge preparations for inmates 575 website, as described in Chapter V. with HIV/AIDS. For inmates with known discharge dates, FMCS has an established discharge protocol. The inmate is seen by an HIV/AIDS TREATMENT FMCS case manager within 120 days of a Depending on the inmate's knowledge of his planned discharge, if possible. During this or her HIV status, CCHPS has established meeting, the inmate and case manager several distinct treatment protocols modeled begin the process of contacting community on CDC guidelines.569 First, inmates with an providers and locating health care established history of HIV infection are resources.576 The most significant obstacle enrolled in the HIV Chronic Care Clinic.570 to effective discharge planning is the According to the CCHPS protocol, these unscheduled release of inmates.577 These inmates must receive a medical evaluation inmates may not have the opportunity to by a chronic care physician to assess HIV participate in discharge planning. status within 10 days of their initial intake On the whole, there are discharge protocols physical.571 Second, inmates who currently in place that would provide D.C. Jail inmates are on antiretroviral medications and who with the information they need for re-entry know the names and doses of their into the community. However, these medications are placed on the same protocols are underutilized because of the medications by the intake physician.572 Third, number of unscheduled releases and an
104 HIV/AIDS IN THE NATION'S CAPITAL apparent lack of communication among a full month's supply while they transition to various vendors and departments at the D.C. community-based HIV/AIDS services. Jail. More coordination between the D.C. Jail Institutional Records Department and ADAP FUNDING the health care providers would increase HRSA specifically addressed the issue of the number of inmates reached by discharge using ADAP funds for services for the planners. This could be tied into CCHPS's incarcerated through Policy Notice 01-01.580 new policy of making sure each released While both the Ryan White CARE Act and inmate has received his/her medication or Policy Notice 01-01 make clear that ADAP has signed a refusal. funds can be used to purchase HIV/AIDS medications, those authorities also specify PROVISION OF HIV/AIDS a significant limitation on the use of those MEDICATION AT DISCHARGE funds: ADAP funds cannot be used to purchase HIV/AIDS medications where the As HIV-positive inmates leave the D.C. state (which is defined to include the Jail and the CTF, a major concern involves District)581 by law is already obligated to continuity of treatment, particularly for those provide those medications to the who are on antiretroviral medication. As incarcerated or where the state voluntarily mentioned in Chapter VI, any disruption of has adopted a practice of doing so.582 Known antiretroviral therapy increases the likelihood as the "maintenance of effort" provision, of the development of viral resistance. In the law and policy require that ADAP funds order to prevent an interruption in treatment, HIV/AIDS AMONG THE INCARCERATEDCHAPTER IX: supplement rather than supplant existing it is critical for an inmate to receive an state funding sources for HIV/AIDS adequate supply of medication at discharge. medications for the incarcerated.583 As the primary vendor for medical and As the District already provides HIV/AIDS mental health services, CCHPS is involved medications to the incarcerated, as well as a in the discharge of inmates with scheduled 7-day supply at discharge, the "maintenance releases.578 Because of the significant of effort" requirement prohibits the use of number of unscheduled releases, oftentimes ADAP funds for the purchase of those the medical staff is not informed prior to an medications. ADAP funds could be used, inmate's release. CCHPS’ policy provides however, to purchase an additional 21-day that upon discharge inmates receive a 7-day supply to provide to inmates at discharge, supply of their prescribed medications.579 provided they have been enrolled in an ADAP When an inmate is about to be released, the program through the discharge planning D.C. Jail Institutional Records Department is process.584 Thus, the inmate would have a supposed to notify the pharmacy staff, who full four-week supply of medication while delivers the inmate's medications to the transitioning to community-based services. inmate in Receiving and Discharge (R&D); Because the D.C. ADAP eligibility criteria do however, there have been reports that this not specifically exclude inmates, eligibility often does not occur. The pharmacy's hours determinations could likely be made prior to are 8 a.m. to 10 p.m., and there are reports release.585 of inmates being released at all hours of the night. A new policy has been instituted that FEDERAL SUPPLY SCHEDULE inmates cannot leave until they have either PURCHASES received their medications or signed a refusal, but its impact remains uncertain While the District cannot use ADAP funding given the apparent lack of communication to purchase those HIV/AIDS medications it regarding releases. An internal review of the already supplies to inmates during effectiveness of this policy should be incarceration and at discharge, the District conducted. is eligible to and does purchase medication through the Federal Supply Schedule The District should be able to use ADAP (FSS).586 Prices on the FSS typically offer funds to purchase an additional three weeks some level of discount, and in some cases worth of antiretrovirals to provide to inmates those discounts can be significant. Use of upon discharge, thereby providing them with the FSS to purchase HIV/AIDS and other
DC APPLESEED CENTER 105 medications provides a significant source at two BOP facilities: Danbury Federal of savings and should be continued. Correctional Institution in Connecticut and Alderson Federal Prison Camp in West OTHER ALTERNATIVES Virginia. Our Place also conducts HIV/AIDS In addition to exploring funding possibilities peer education programs at the same under ADAP, the District should consider facilities. other medication financing options. The District should enroll eligible inmates in DISCHARGE PLANNING BY THE Medicaid prior to release, so that Medicaid COURT SERVICES OFFENDER covers the provision of medication at SUPERVISION AGENCY discharge. The District also should consider CSOSA, the D.C. parole and probationary partnering with pharmaceutical companies oversight agency, has instituted a pre-release to obtain free medications for inmates at program for District inmates in BOP release. For example, Secure Pharmacy Plus, facilities.589 CSOSA conducts its program a pharmacy vendor at several correctional on a quarterly basis at Rivers Correctional facilities around the country, offers HIV- Institution (Rivers) in North Carolina, an positive inmates discharge planning services all-male facility that houses about 1,000 of and a 30-day supply of free medication the roughly 7,000 D.C. inmates in BOP through the SecureRelease Program.587 facilities nationwide.590 Presentations by This program is made possible through representatives of community providers, cooperation with five major pharmaceutical including Unity Health Care and HIV companies.588 Community Coalition, are made for those scheduled to be released during the next quarter, usually about 200 males.591 The inmates are also given a packet with DISCHARGE important facts and contact information PLANNING FOR D.C. related to medical services. CSOSA should expand the pre-release INMATES IN FEDERAL program. The videoconferencing format that has been implemented to facilitate FACILITIES participation of local organizations in the Since District inmates are now in prisons Rivers pre-release program should be used throughout the country, discharge planning to reach inmates in other BOP facilities. services are essential to ensure adequate The use of videoconferencing should help health care upon their return to the District. reduce costs by eliminating the need to travel to Rivers. DISCHARGE PLANNING BY OUR PLACE DC Our Place DC operates a pre-release discharge planning program for D.C. women REENTRY ISSUES FOR EX-OFFENDERS Housing Issues Several organizations receive funds to offer One of the biggest obstacles for ex-offenders is obtaining housing. assistance to inmates reentering the As explained in Chapter VI, the problems of affordable housing in community, including Our Place DC, Us the District are largely beyond the scope of this study, but they Helping Us, and Miracle Hands. Like have an enormous impact on reentering inmates. For HIV-positive discharge planning services, reentry services ex-inmates in particular, the general housing shortage is coupled help ensure continued health care by with the difficulty of finding housing that will accept them. There referring former inmates to local providers. are a few supportive housing programs that serve ex-offenders, such as Safe Haven and Miracle Hands, but these are insufficient. Lack of housing affects released inmates' well-being directly and indirectly.
106 HIV/AIDS IN THE NATION'S CAPITAL SERVICES BY LOCAL VENDORS HIV/AIDS counseling, testing, and education IN THE DISTRICT vendors should be reduced to avoid duplication of services and access issues. Three local vendors assist ex-offenders with Rapid Testing. Given the rapid turnover at reentry into the community. Our Place DC the D.C. Jail and CTF and the potentially high provides case management, housing and job HIV infection rates of the incarcerated, rapid placement assistance, and other services to testing should be implemented. formerly incarcerated women. Us Helping Us works primarily with MSM and transgender Substance Abuse Treatment. The DOC ex-offenders, helping them link to community should augment substance abuse treatment services through case management. Miracle programs for inmates. Given the correlation Hands provides ex-offenders with supportive among substance abuse, incarceration, and housing and also provides traditional HIV infection, substance abuse treatment discharge planning services at a local halfway should be a priority at the D.C. Jail and CTF, house. and such programs should be expanded. HIV/AIDS Medication. DOC should institute SERVICES BY CSOSA IN THE safeguards to ensure that HIV-positive DISTRICT inmates are not released without medication. DOC should use ADAP funding to provide a Some inmates are released from the BOP 30-day supply of medication at discharge. The and placed on parole, whereas others are District should also enroll eligible inmates in released directly into the community. Paroled Medicaid at discharge and explore partnering HIV/AIDS AMONG THE INCARCERATEDCHAPTER IX: inmates from both the DOC and the BOP with pharmaceutical companies to provide become part of CSOSA's Transitional free antiretrovirals at discharge. Intervention Parole Services.592 These inmates are assigned a parole officer to Discharge Planning. CSOSA should increase assist them with reentry services and may the number of federal facilities in which reside in a halfway house during their initial discharge planning services are offered to reentry period. Inmates released without District inmates. parole supervision are responsible for locating their own health care provider. For those who have not received discharge planning services, obtaining health care CONCLUSION coverage and services may be more difficult. Although progress has been made in the quality of health care afforded to the District's inmates and ex-offenders, there are some areas in need of improvement. SUMMARY OF By ensuring the provision of a sufficient supply of prescription drugs at discharge, RECOMMENDATIONS the availability of substance abuse treatment, Data. HAA should improve collection and and the coordination of services during dissemination of data on the incidence incarceration, the District could better of HIV/AIDS among the incarcerated. In address HIV/AIDS among its inmates. In addition, HAA should conduct regular HIV addition, more inmates in the federal system prevalence studies. should receive discharge planning services. HIV/AIDS Service Provider Access. HAA and the DOC should increase communication and improve coordination of HIV/AIDS services. Rather than maintaining the current system of one vendor for medical services and multiple vendors for HIV/AIDS counseling, testing, and education services, the DOC ideally should have a single vendor provide all of these services in the D.C. Jail and the CTF. At a minimum, the number of
DC APPLESEED CENTER 107 ENDNOTES 507 Interviews with District of Columbia providers and government officials. 485 Laura M. Marushak, HIV in Prisons, 2001, BUREAU OF JUSTICE STATISTICS BULLETIN 1 (Jan. 2004), available at 508 Id. http://www.ojp.usdoj.gov/bjs/abstract/hivp01.htm (last visited July 509 Id. 19, 2001) [hereinafter "HIV in Prisons 2001"]. 510 Interview with District of Columbia provider. 486 Id. at 2 tbl. 1; Basic Statistics, supra note 26; Annual Population Estimates, supra note 67. 511 Id. 487 2003 Epi Profile, supra note 32, at 36. 512 Id. 488 Interview with District of Columbia provider. 513 Interview with District of Columbia government official. 489 General Accounting Office, District of Columbia: Issues Related to 514 Interview with District of Columbia provider. the Youngstown Prison Report and Lorton Closure Process 515 Interviews with District of Columbia government officials. (GAO/GGD 00-86) 3 (2000), available at http://www.gao.gov/new.items/gg00086.pdf [hereinafter "Lorton 516 Telephone Interview with Kate Monaco-Kline, San Francisco Closure"]. County Jail, and Joe Goldenson, Medical Director, Forensic Services, San Francisco County Jail (Nov. 4, 2004). 490 Id. at 3. 517 Telephone Interview with Royanne Schissel, Director of Nursing, 491 Id. at 3-4. San Diego County Jail (Nov. 22, 2004). 492 S. REP. NO. 106-088 at 14 (1999), available at 518 Telephone Interview with Barry Zack, Executive Director, http://thomas.loc.gov/cgi-bin/cpquery/?&db_id=cp106&r_n=sr088. Centerforce (Dec. 15, 2004). 106&sel=TOC_43640& (last visited July 19, 2005). 519 Id. 493 U.S. General Accounting Office, D.C. Criminal Justice System: Better Coordination Needed Among Participating Agencies (GAO- 520 Interview with District of Columbia provider. 01-187) 7-8 (2001), available at 521 District of Columbia Department of Corrections, D.C. CDF and CTF http://www.gao.gov/new.items/d01187.pdf (last visited July 25, Health Services Protocol for Chronic Care Clinic 1 (June 2003) 2005); National Capital Revitalization and Self-Government [hereinafter "Health Services Protocol"]. Improvement Act of 1997, Pub. L. No. 105-33 § 11201(b), 111 Stat. 522 Interview with District of Columbia provider. 251, 734 (1997) [hereinafter "Revitalization Act"]. 523 Id. 494 Revitalization Act, supra note 493; Tim Roche et al., Returning Adult Offenders in DC: A Roadmap to Neighborhood Based Reentry 524 Id. 17 (Apr. 2002), available at http://www.justicepolicy.org/ 525 Id. downloads/DCTAFinalDraft.pdf (last visited July 25, 2005). 526 Interview with District of Columbia provider. 495 Id. 527 Id. 496 District of Columbia Department of Corrections, Central Detention Facility, available at http://www.doc.dc.gov/doc/cwp/ 528 Id. view,a,3,q,491403.asp (last visited July 25, 2005). 529 Id. 497 District of Columbia Department of Corrections, Demographics and 530 Id. Statistics: Average Daily Population for October 2001 through March 2005 at 3, available at 531 Id. http://doc.dc.gov/doc/frames.asp?doc=/ 532 Interview with District of Columbia government official. doc/lib/doc/populationstats/Demographics_and_Statistics_Apr05_ 533 Interviews with District of Columbia provider and government (1).pdf (last visited July 19, 2005) [hereinafter "DOC Average Daily official. Population for October 2001 through March 2005"]. 534 See J.K. Andrus et al., HIV Testing in Prisoners: Is Mandatory 498 District of Columbia Department of Corrections, Correctional Testing Mandatory? , 79 AM. J. PUBLIC HEALTH 840-42 (July Treatment Facility, available at http://www.doc.dc.gov/doc/cwp/ 1989). view,a,3,q,491431.asp (last visited July 19, 2005). 535 Interview with District of Columbia provider. 499 Interviews with District of Columbia government officials and providers. 536 Id. 500Id. 537 Id. 501 DOC Average Daily Population for October 2001 through March 538 District of Columbia Pretrial Services Agency, Strategic Plan: 2000- 2005, supra note 497, at 3. 2005, at 7 (Sept. 2000), available at http://www.dcpsa.gov/foia/ PSAfoiaDocuments/strategicplans/PSASP2000-2005.pdf (last 502 District of Columbia Department of Corrections, D.C. Department of visited July 19, 2005). Corrections Facts and Figures 11 (June 2005), available at http://www.doc.dc.gov/doc/frames.asp?doc=/doc/lib/ 539 Id. at 7. doc/populationstats/DC_Department_of_Corrections_Facts_and_Fi 540 Id. at 8. gures_June_05.pdf (last visited July 25, 2005) [hereinafter "DOC Facts and Figures"]. 541 Testimony of Paul Quander, Jr., Director, Court Services and Offender Supervision Agency for the District of Columbia, U.S. 503 Id. at 5. Senate Committee on Appropriations Subcommittee on the District 504 Id. at 6. of Columbia Appropriations Hearing (Apr. 20, 2005), available at http://appropriations.senate.gov/hearmarkups/SenateTestimony- 505 When medical services at the D.C. Jail were in receivership several cleared4-15-05.htm (last visited July 25, 2005). years ago, Hogan & Hartson provided pro bono legal services to the court-appointed receiver, Dr. Ronald Shansky. Subsequently, 542 Interview with District of Columbia government official. Hogan & Hartson has provided legal assistance to the jail medical 543 Id. contractor, CCHPS, of which Dr. Shansky is now the interim medical director. During and after the receivership, Karen Schneider, DC 544 Id. Appleseed HIV/AIDS Project Director, was extensively involved in 545 Id. overseeing medical care at the D.C. Jail, including serving as the court-appointed Special Master for five years. 546 Interview with District of Columbia government official. 506 Interviews with District of Columbia government officials.
108 HIV/AIDS IN THE NATION'S CAPITAL 547 District of Columbia Pretrial Services Agency, Draft Strategic Plan: 574 Interview with District of Columbia provider. 2005-2010, at 13 (Summer 2003), available at 575 Id. http://www.dcpsa.gov/foia/PSAfoiaDocuments/strategicplans/PSA SP2005-2010.pdf (last visited July 19, 2005). 576 Id. 548 Robert L. DuPont, et al., Washington-Baltimore High Intensity 577 Id. Drug Treatment Area Technical Report, The Effect of W/B HIDTA- 578 Interview with District of Columbia provider. Funded Substance Abuse Treatment on Arrest Rates of Criminals Entering Treatment in Calendar Year 2001, at 3-4 (Aug. 31, 2004), 579 Id. available at http://www.hidta.org/programs/treatment/ 580 Department of Health and Human Services, Health Resources and 040831_Sept_31_2004_HIDTA_technical_report.pdf (last visited Services Administration, The Use of Ryan White CARE Act Funds July 25, 2005). for Transitional Social Support and Primary Care Services for 549 Id. Incarcerated Persons (Policy Notice 01-01) (July 23, 2001), available at http://hab.hrsa.gov/law/0101.htm (last visited July 19, 2005) 550 Interview with HIDTA official. [hereinafter "The Use of Ryan White Funding for Incarcerated 551 Interviews with various corrections officials. Persons"]. 552 Interviews with Arlington County and Prince George's County 581 42 U.S.C. § 300ff-28(a)(3). corrections officials. 582 The Use of Ryan White Funding for Incarcerated Persons, supra 553 Interview with Montgomery County corrections official. note 580. 554 Interviews with various corrections officials. 583 Telephone Interview with Johanne Messore, Project Officer, Division of Service Systems, Health Resources and Services 555 Interview with Prince George's County corrections official. Administration (Apr. 8, 2005). 556 Id. 584 Id. 557 Interview with Montgomery County corrections official. 585 District of Columbia Department of Health, AIDS Drug Assistance 558 Id. Program Questions and Answers. 559 Interview with Arlington County corrections official. 586 See U.S. General Services Administration, Eligibility to Use GSA Sources of Supply and Services, GSA ADM 4800.2E, § 7.b.3 (Jan. 560 Id. 3, 2000), available at http://www.gsa.gov/gsa/cm_attachments/ HPE X HIV/AIDS AMONG THE INCARCERATEDCHAPTER IX: 561 Interview with Fairfax County corrections official. GSA_BASIC/Eligibility%20to%20Use%20GSA%20Sources_R2E- 562 Id. rKS_0Z5RDZ-i34K-pR.doc (last visited July 25, 2005). This GSA Order gives the District of Columbia access to FSS pricing in 563 DOC Facts and Figures, supra note 502, at 3. accordance with section 201 of the Federal Property and 564 Centers for Disease Control & Prevention, Substance Abuse Administrative Services Act of 1949, as amended, and codified at Treatment for Drug Users in the Criminal Justice System 1-2 (Aug. 40 U.S.C. § 502(a)(3) (originally codified at 40 U.S.C. § 481). 2001), available at http://www.cdc.gov/idu/facts/cj-satreat.pdf 587 Prison Health Services, Inc., America Service Group Acquires (last visited July 25, 2005). Stadtlanders Corrections Division, THE PULSE 2 (Spring/Summer 565 Interview with Robert Greifinger, Consultant, District of Columbia 2001), available at http://www.prisonhealth.com/pdf/ Department of Corrections (June 15, 2004); Telephone Interview nwsltrsum01.pdf (last visited July 19, 2005); see also Secure with Barry Zack, Executive Director, Centerforce, (Dec. 15, 2004). Pharmacy Plus, Secure Release, available at http://www.securepharmacyplus.com/securerelease.htm (last 566 Interview with District of Columbia provider. visited July 19, 2005). 567 Id. 588 America Service Group Acquires Stadtlanders Corrections Division, 568 Interview with Royanne Schissel, Director of Nursing, San Diego supra note 587. County Jail (Nov. 22, 2004). 589 Interview with Staff Members of Court Services and Offender 569 Interview with District of Columbia provider. Supervision Agency for the District of Columbia (July 8, 2004). 570 See Health Services Protocol, supra note 521, at 1. 590 Id. 571 Id. 591 Id. 572 Id. 592 Id. 573 Id.
DC APPLESEED CENTER 109
PART 2: CHAPTER X CONCLUSION
The recommendations set forth in this report will require action by many and will take significant time to implement. To facilitate this process, Appendix B sorts the recommendations according to the agency responsible for their implementation. DC Appleseed is committed to collaborating with the government, providers, and others in implementing the recommendations. In order to track implementation efforts, DC Appleseed will issue periodic updates. Implementation should commence immediately. The health of the District's residents depends on it.
DC APPLESEED CENTER 111
APPENDIX A: LETTER FROM THE DEPUTY MAYOR
DC APPLESEED CENTER 113 114 HIV/AIDS IN THE NATION'S CAPITAL PEDXA LETTER FROM THE DEPUTY MAYORAPPENDIX A:
DC APPLESEED CENTER 115
APPENDIX B: RECOMMENDATIONS
DC APPLESEED CENTER 117 HAA DOH z Expand HAA's website z Expand access to STD prevention services and publicize the services z Fill vacant positions in the Surveillance Division z Implement and enforce routine HIV testing at the District TB Clinic z Collect and disseminate HIV and AIDS data and make such data available to the public z Gather and disseminate data on the number and characteristics of IDUs and z Evaluate HAA's role in working with the CPG, particularly in terms of providing substance abusers in the District timely and accurate data z In collaboration with HAA, collect data regarding comorbidities z Promote HIV/AIDS reporting requirements and work with the Attorney General to z Institute a pay-for-performance system enforce HIV/AIDS reporting requirements based on quality assurance standards
z Combine AIDS and HIV databases into a z Increase interagency collaboration to single database system improve treatment and care for comorbidities z Ensure that surveillance data are reinforced at a remote data storage site z Develop a centralized application process, to be administered by IMA, for the z Reform the grants management system by ensuring that grantees are paid in a timely enrollment and eligibility verification for manner and grant renewals are Medicaid, the Alliance, Ticket to Work, expeditiously processed ADAP, and other programs z Expand Medicaid benefits to include case z Implement routine HIV/AIDS testing throughout the District management z Maximize Medicaid enrollment and ensure z Expand the availability of rapid testing that all subcontractors who provide z Increase condom distribution Medicaid-covered services are Medicaid z Provide prevention case managers with certified adequate specialized training on a regular z Explore the possibility of increasing basis and facilitate better coordination Medicaid rates for HIV/AIDS services between prevention case managers and Ryan White case managers
z Collaborate with DMH to provide adequate training on HIV/AIDS issues to mental DCPS health workers z Work with the Board of Education to z Facilitate prevention interventions, develop school-wide standards regarding including testing and counseling, which grade levels receive HIV prevention education, and condom distribution for the education, what the content of such mentally ill at mental health provider sites education is, and the quality of the z Monitor adherence to revised case education provided management protocols and provide case z In collaboration with CBOs, develop managers with regular substantive training standardized performance measures for and current information about available HIV education that are used to evaluate all resources and services for their clients schools and all HIV/AIDS programs z Fund complementary services provided by operating in public schools the privately-funded syringe exchange z Establish guidelines and policies to program and encourage community-based improve the collection of data regarding organizations that provide complementary HIV/AIDS programs and services in the HIV/AIDS services to collaborate and co- schools locate with the syringe exchange program z Improve coordination of offices responsible z Consider expanding the ADAP formulary for health policy and health education and consider creating a school health office
118 HIV/AIDS IN THE NATION'S CAPITAL that includes the liaison to the School Nursing Program, HIV/AIDS Education, and DOC other health-related programs z Conduct regular HIV prevalence studies of the incarcerated population and make data z Improve communications with the public about DCPS' HIV/AIDS program, including publicly available updating the DCPS website with relevant z Work with HAA to increase communication information and improve coordination of HIV services in the D.C. Jail and CTF
z Expand substance abuse treatment programs in the D.C. Jail and CTF
BOARD OF z Provide condoms to inmates at discharge EDUCATION z Institute safeguards to ensure that HIV- z Work with DCPS to develop school-wide positive inmates are not released without standards regarding which grade levels medication receive HIV prevention education, what z Use alternate funding sources, including the content of such education is, and the ADAP, to provide 30 days of medication to quality of the education provided HIV-positive inmates at discharge z Review and amend the outdated D.C. z Work with HAA to implement rapid testing Municipal Regulations relating to HIV/AIDS at the D.C. Jail and CTF in the school system and ensure that school staff is trained regarding these regulations PEDXB RECOMMENDATIONS APPENDIX B: z Establish an "Advisory Council on Student CSOSA and School Health" that would include z Increase the number of federal facilities participation from DOH, HAA, CNMC, in which discharge planning services are CBOs, the D.C. Council and Mayor's offered to District inmates Office, local children's health advocates, school nurses, parents, and national experts DISTRICT OFFICIALS AND ADVOCATES STD DIVISION z Continue efforts to persuade Congress z Provide routine rapid testing at the STD to lift the ban on the use of local funds Clinic for syringe exchange programs z Work with HAA to strengthen HIV prevention efforts through STD prevention z Ensure that all clients at the STD Clinic receive counseling regarding STD and HIV prevention
APRA z Increase the availability of and access to substance abuse treatment z Provide routine rapid testing at all APRA sites
DC APPLESEED CENTER 119
APPENDIX C: RECOMMENDATIONS FOR IMPROVING THE DISTRICT'S WEB-BASED HIV/ AIDS RESOURCES
DC APPLESEED CENTER 121 The Internet has become an populations that are at a high risk of contracting HIV.594 Prevention messages important venue for making include warnings about risk behavior and guidance on specific harm reduction and information available to prevention measures. Typically, these consumers and providers, prevention messages encourage testing. There is limited information on HAA's advocates and academics, website about prevention measures. and policy makers and public Although HAA's website provides a list of testing sites, it fails to include anything officials. The District's web- specifically designed to encourage and based HIV/AIDS resources promote testing. Furthermore, there is no specific information should be enhanced. on services available for HIV-positive individuals. Existing provider lists on HAA's website contain limited information. HAA should maintain an organized resource HAA'S WEBSITE directory of HAA-funded providers that HAA's website should be an important includes a description of each organization, mechanism for educating the public and its address and phone number, the services informing the community about the HIV/AIDS provided, a description of eligibility epidemic in the District. Although the requirements, and a link to its website, website was modified recently in response if one exists.595 to Councilmember Catania's request, the In addition to providing information for the website should be significantly expanded. public and consumers, many jurisdictions use An examination of other websites of similar their websites to assist HIV/AIDS providers HIV/AIDS government agencies throughout by providing basic information, training the country offers many models for calendars, and contacts for the services improving HAA's website. available to providers. For example, the Currently, HAA's website provides a basic Seattle/King County website provides description of programs the agency runs or technical assistance to CBOs on grant funds and relies on links to external websites writing, information management, and to provide consumers with information on organizational and program development, HIV/AIDS. One of the website's greatest with necessary contact information.596 HAA's flaws is the complete lack of basic only provider-oriented content is a list of information on HIV/AIDS, how HIV is grants available through HAA, with contact transmitted, how HIV/AIDS impacts District information, and links to a limited number of residents, and what local resources are federal grant programs. At a minimum, HAA available for the prevention and treatment should include a clear description of the of HIV/AIDS. In addition to external links to various services and training available to educational information, HAA's website regional providers, with up-to-date contact should include this basic information about information for each program. Ideally, HAA HIV/AIDS, such as the information provided would develop a comprehensive collection of on the HIV/AIDS websites for Illinois, New resources that providers could rely on for York City, Seattle/King County, and educational materials, guidance, news, and Maryland.593 This educational information technical support. should be available in multiple languages HAA's website has eight links to external to meet the needs of District residents sites on its "Helpful Links" page. All but for whom English is not a first language. two links are for national websites. Many HAA should also use its website as a websites include a significantly larger resource to educate the public about specific selection of links to other useful sites and HIV-prevention strategies. On their websites, resources.597 HAA's website is especially Seattle/King County and Illinois include lacking in links to other local agencies' information specifically targeted to websites that provide District-specific
122 HIV/AIDS IN THE NATION'S CAPITAL information and services. Furthermore, the z Local news: News related to the system website lacks clear information regarding of prevention and care for HIV/AIDS culled enrollment in ADAP, Medicaid, or other from all of our local news sources, services provided through the IMA. including: the Washington Post, the HAA also sponsors two other websites: Washington Times, the Washington Blade, www.hivcounts.net, which provides the D.C. Examiner, the Common information on HIV testing reporting Denominator, City Paper, the Current requirements to medical personnel; and newspapers (Northwest Current, etc.), www.technetdc.com, a capacity-building Roll Call, the Hill, and others. project for local providers that gives z National news: Relevant HIV/AIDS-related information on local training and resources news from around the country. available. Neither of these websites is z Calendar: A comprehensive calendar could mentioned on HAA's website. These sites include, for example, entries for technical should be regularly updated and linked to or assistance trainings, HIV Prevention RECOMMENDATIONS FOR IMPROVING APPENDIX C: THE DISTRICT'S WEB-BASED HIV/AIDS RESOURCES merged with HAA's main website. Community Planning Group meetings, HAA's website should be expanded to Ryan White Title I Planning Council include specific information on HIV/AIDS meetings, Case Management Operating generally and the state of the epidemic Committee meetings, Mayor's Advisory locally. The website should be a resource Committee meetings, fundraising events, guide that includes local HIV/AIDS and relevant D.C. Council hearings. surveillance data, HIV prevention information, z Funding opportunities: This section could a listing of local resources, and relevant include public grant announcements and information for service providers. private grant applications and information.
z HIV/AIDS 101: The basics on the epidemic and links to additional information (including the AIDS Education Global NON- Information System, AEGis.com, HIV GOVERNMENTAL InSite, and The Body). z HIV Services in the District: A carefully WEB RESOURCE indexed directory (by service type, provider In addition to websites operated by local name, etc.) with information about each health departments, most major U.S. cities provider, including contact information, have at least one comprehensive, and information on services provided. The independent web-based resource on directory could include all relevant HIV/AIDS operated by a non-governmental, services, including HIV/AIDS prevention HIV-focused organization that is well and care, hepatitis C, TB, substance abuse, recognized by the community – often the sexually-transmitted diseases, and mental local HIV grant-making organization (e.g., health. AIDS Project Los Angeles and AIDS z Training/technical assistance 598 Foundation of Chicago). One very good opportunities: Information about all reason for this is that a comprehensive web- training and technical assistance based resource on HIV/AIDS can provide a resources, including the American critical link to needed information and a Psychological Association's Behavioral neutral forum for widely-dispersed and Social Science Volunteer Program, stakeholders in the HIV community. and the CDC's training centers. The District does not have this independent z Public documents: Surveillance reports, source of information on HIV/AIDS. An data, public hearing testimony, minutes organization such as the Washington AIDS from meetings, local and national Partnership – a philanthropic collaborative protocols, and others. affiliated with the National AIDS Fund and Washington Grantmakers – could operate an independent HIV/AIDS website. The website could include:
DC APPLESEED CENTER 123 ENDNOTES 596 See generally Public Health – Seattle & King County, HIV/AIDS Program Technical Assistance for Community Based Organizations 593 See generally Illinois Department of Public Health, HIV/AIDS, (CBO), available at http://www.metrokc.gov/health/apu/ available at http://www.idph.state.il.us/aids/default.htm (last menucbo.htm (last visited July 25, 2005). visited July 25, 2005); New York City Department of Health and Mental Hygiene, HIV/AIDS Information, available at 597 See generally Public Health – Seattle & King County, HIV/AIDS http://www.nyc.gov/html/doh/html/ah/ahbasic.shtml (last visited Program Links to HIV-related Websites, available at July 25, 2005); Public Health – Seattle & King County, HIV/AIDS http://www.metrokc.gov/health/apu/links/index.htm (last visited Program Questions and Answers About HIV and AIDS, available at July 25, 2005); Maryland Department of Health and Mental http://www.metrokc.gov/health/apu/basic/index.htm (last visited Hygiene, Locating HIV/AIDS News and Information, available at July 25, 2005); Maryland Department of Health and Mental http://www.dhmh.state.md.us/AIDS/infohiv.htm (last visited July Hygiene, HIV Infection and AIDS, available at 25, 2005). http://www.dhmh.state.md.us/AIDS/trnsmit.htm (last visited July 598 See generally AIDS Project Los Angeles, available at 25, 2005). http://www.apla.org/ (last visited July 25, 2005); AIDS Foundation 594 See generally Public Health – Seattle & King County, HIV/AIDS of Chicago, available at http://www.aidschicago.org/home/ Program Information for Specific Populations, available at index.php (last visited July 25, 2005). http://www.metrokc.gov/health/apu/groups/index.htm (last visited July 25, 2005); Illinois Department of Public Health, HIV/AIDS: AIDS and Those It Affects, available at http://www.idph.state.il.us/ aids/people_affected.htm (last visited July 25, 2005). 595 See generally Massachusetts Department of Public Health, HIV/AIDS, Hepatitis, STD and Substance Abuse Services & Resources (July 2005), available at http://www.mass.gov/dph/aids/ services/hivresourceguide.pdf (last visited July 25, 2005); AIDS Office, San Francisco Department of Health, 2003 HIV Prevention and Social Services in San Francisco, available at http://www.sfdph.org/Services/HIVPRevSvcs/2003HIVPrevySocialS vcs4SF.pdf (last visited July 25, 2005); Public Health – Seattle & King County; HIV/AIDS Program Who Does What in Seattle & King County: Seattle/King County HIV/AIDS Resources, available at http://www.metrokc.gov/health/apu/resources/list.htm (last visited July 25, 2005).
124 HIV/AIDS IN THE NATION'S CAPITAL APPENDIX D: THE DISTRICT’S HEALTH CARE COVERAGE PROGRAMS
DC APPLESEED CENTER 125 This appendix summarizes Medicaid coverage of emergency care, but may not be eligible for the full range the eligibility requirements of Medicaid services if they entered the and benefits provided by the United States after 1996. The District has chosen to alter its District's Medicaid program, categorical, income, and resource the Alliance, and Ryan White. requirements, with federal government approval, to allow more residents to be eligible for Medicaid. These requirements are discussed below.
MEDICAID CATEGORICAL ELIGIBILITY REQUIREMENTS ELIGIBILITY The federal government provides matching The District's Medicaid program applies funds to states to cover five categories of the five criteria required by federal law to low-income people: children; pregnant determine whether an individual is eligible women; adults in families with dependent for coverage. These criteria are: residency, children; the elderly; and the disabled. immigration status, categorical status, These categories reflect Medicaid's historical income, and resources. Individuals must be connection to federal income support residents of the District to be eligible for the programs, such as the Aid to Families District's Medicaid program and must be with Dependent Children (AFDC) and U.S. citizens or legal immigrants to the Supplemental Security Income (SSI) country. Legal immigrants are eligible for programs. Although many Medicaid beneficiaries do not receive any federal D.C. Medicaid income support, the Medicaid laws continue to use these categories to define eligibility. The following groups are eligible for Medicaid under the Unfortunately, these categories tend to District's plan: exclude many low-income individuals who z Children up to age 19 and their parents and pregnant women are young, childless, and not disabled. i with family incomes at or below 200 percent of FPL; Medicaid's categorical eligibility criteria often z Individuals eligible for SSI with incomes at 74 percent of FPL;i place low-income people with HIV/AIDS in 599 z Aged, blind, and disabled persons with incomes at 100 a "Catch-22." Appropriate therapies may percent of FPL;i prevent HIV-positive individuals from becoming disabled, yet states are not z Medically needy individuals with incomes at 53 percent of FPL allowed to provide Medicaid coverage until ii or couples at 41 percent of FPL; these individuals become disabled. Childless z Childless adults aged 50-64 with incomes up to 50 percent of men are most likely to be affected by this FPL;iii eligibility limitation because they typically z Uninsured HIV-positive adults who work at least 40 hours per qualify for Medicaid only when they become month, with incomes up to 300 percent of FPL;iv and disabled and then can be subject to the lowest maximum income requirement. z HIV-positive adults with incomes up to 100 percent of FPL.v Women tend to fare slightly better under Beneficiaries also must meet the District's assets tests, which these criteria because they are more likely vary by eligibility category. to have children in their households, providing access to Medicaid at higher i. Kaiser Family Foundation, District of Columbia: Medicaid Eligibility, http://www.statehealthfacts.org. income levels, as discussed below. ii. Kaiser Family Foundation, District of Columbia: Medically Needy Eligability as a Percent of Federal Poverty Level, 2001, http://www.statehealthfacts.org. It is possible, however, for low-income, HIV- iii. CMS, Fact Sheet: District of Columbia 1115 for Childless Adults, http://www.cms.hhs.gov/medicaid/ positive individuals to qualify for Medicaid, 1115/dccafact.pdf. even if they do not fit into an eligibility iv. HAA, Quarterly Progress Report for the Demonstration to Maintain Independence and Employment category. For example, one may be declared Grant (#P-11-91421-3) for July 1, 2004 - Sept. 30, 2004. "presumptively disabled." Persons with HIV v. CMS, Fact Sheet: District of Columbia HIV 1115 Demonstration, http://www.cms.hhs.gov/medicaid/ are considered to be "presumptively disabled 1115/dchiv1115.pdf. if they can document one or more of a
126 HIV/AIDS IN THE NATION'S CAPITAL specified listing of opportunistic infections, who meet both the category and income cancers, or conditions; they need not be requirements. Federal law defines 28 diagnosed with AIDS."600 This status allows eligibility categories – combinations of individuals to receive SSI benefits and be categorical eligibility and income and eligible for Medicaid without waiting for a resource qualifications – that states must formal declaration that the individual is cover to receive federal matching funds.602 disabled. The second way is for the state to Individuals who qualify for these categories use waivers or demonstration programs to are not required to spend down to receive expand its Medicaid program. The District Medicaid benefits. Individuals who qualify has used Medicaid demonstration programs for any of the 21 additional optional eligibility to expand its categorical eligibility options to categories for which states can receive include HIV-positive individuals who work at matching funds, including persons covered least 40 hours per month or who have under the waiver programs discussed below, incomes below the federal poverty line. can spend down to qualify for Medicaid. This option provides access to Medicaid coverage Are persons with HIV/AIDS for some people with HIV/AIDS after they have paid some of their own medical "disabled" for purposes of expenses. Medicaid eligibility? PEDXD THE DISTRICT’S HEALTH CARE COVERAGEAPPENDIX D: PROGRAMS z Persons with AIDS: Generally, yes. If RESOURCE ELIGIBILITY REQUIREMENTS AIDS prevents them from engaging in The resource eligibility requirements set an any "substantial gainful activity." upper limit on the value of assets, including cars and savings, that a beneficiary may own z HIV-Positive Individuals: Maybe, if they can document one or more of a specified and remain eligible for Medicaid. States' listing of opportunistic infections, resource standards vary and often are tied cancers, or conditions, they may be to the AFDC standards in place in 1996, when AFDC was ended,603 or the current declared "presumptively disabled" and SSI standards. The resource level and the thus eligible for Medicaid. methodology used to determine an individual's resources also vary by state and category of eligibility. INCOME ELIGIBILITY REQUIREMENTS The District's resource limits for categorically The District's Medicaid program meets the needy persons are $2,600 for individuals and minimum federal requirements for income $3,000 for couples.604 eligibility standards. In some cases, the District has raised the income levels to allow more people to qualify for Medicaid. For example, although the federal minimum requirements set higher income standards Federal Poverty Level in 2005: for children ages five and below than for z $9,570 per year for one person those age six and above, the District applies z $16,090 per year for a three-person family the same higher income standard, 200 percent of the federal poverty level (FPL), z $19,350 per year for a four-person family to all children, regardless of age, to ensure that all children in a family receive Department of Health and Human Services, Annual Update of the HHS Poverty Guidelines, 70 Fed. Medicaid coverage.601 Reg. 8,373-8,375 (Feb. 18, 2005) (last visited July 21, 2005). In most states and the District, individuals who meet the categorical requirements but SSI Payments for Low-Income Aged, Blind, and not the income and resource tests can qualify for Medicaid coverage by deducting Disabled Persons in 2005: their health care expenses from their income z $6,948 per year for one person (a process called “spending down”). Beneficiaries who use this method are Supplemental Security Income (SSI) In the District of Columbia, SSA Publication No. 05-11162 known as "medically needy," as distinguished (Jan. 2005), available at http://www.ssa.gov/pubs/11162.html (last visited July 21, 2005). from the "categorically needy" beneficiaries
DC APPLESEED CENTER 127 BENEFITS unreasonably restrict coverage of effective treatments (including FDA-approved The District's Medicaid program covers a full combination therapy) for HIV/AIDS-infected range of health benefits, which are described individuals."606 in the District's State Medicaid Plan. Under federal law, state programs must cover the following 12 categories of services: 1. Physicians' services; ALLIANCE 2. Laboratory and X-ray services; 3. Inpatient hospital services; ELIGIBILITY 4. Outpatient hospital services; The Alliance provides free health care to individuals and families who: 5. Early and periodic screening, diagnostic, and treatment services for individuals z live in the District of Columbia; under age 21, such as appropriate z have no health insurance; and immunizations, vision services, and z have income at or below 200 percent of dental services; the FPL. A member's income (before 6. Family planning services and supplies; taxes) must be at or below an amount that 7. Services provided by federally qualified is determined by the number of people in health centers; his or her immediate family. For example, individuals cannot make more than 8. Services provided by rural health clinics; $19,140 a year, while the annual income 9. Nurse-midwife services; for a family of four cannot exceed $38,350. 10. Certified pediatric nurse practitioner or Applicants are first presumptively enrolled family nurse practitioner services; for 30 days from the day they sign the 11. Nursing facility services for individuals 21 enrollment application. Once eligibility is or over; and verified, applicants are enrolled in the program for six months.607 Every six months 12. Home health care services for individuals a member of the Alliance must re-enroll in entitled to nursing facility services.605 the program. At least 30 days before the end District Medicaid beneficiaries usually are of each six-month membership period, a not liable for co-payments for these services. member must call the Member Services In addition to the services mandated by Department for help completing the federal law, D.C. Medicaid also covers recertification paperwork and to set up an prescription drugs, substance abuse appointment for recertification.608 As with treatment services, mental health care, Medicaid, recertification is required to and rehabilitation care. The prescription drug determine whether any changes in the benefit, which is particularly important for beneficiary's financial, health, or residency individuals with HIV/AIDS, offers many critical status since the time of last enrollment affect drugs at very low cost to the patient. the beneficiary's eligibility for the program. Medicaid beneficiaries in the District pay a Applicants are not eligible for the Alliance $1.00 per prescription co-payment for each if they do not meet the three prerequisites prescription drug they purchase. Under discussed above. Applicants are also not federal law, if a state chooses to cover eligible if they are enrolled in other medical prescription drugs in its Medicaid program, health benefit programs, such as Medicaid, it must cover all drugs approved by the Food are receiving Social Security income benefits, and Drug Administration for which the or are admitted to a long-term care facility Secretary of HHS has signed a Medicaid (including nursing homes) for more than rebate agreement. Although states are 30 days.609 allowed to limit coverage through the use of formularies and preferred drug lists and by requiring prior authorization for non-preferred drugs, CMS recommends that states ensure that these limitations "do not excessively or
128 HIV/AIDS IN THE NATION'S CAPITAL BENEFITS drugs may be a challenge. Members must go to one of seven Alliance pharmacies to PRIMARY CARE PROVIDER get a prescription filled. These locations have limited hours and are not open on the If members meet the eligibility requirements weekends.614 The Alliance provides coverage discussed above, they must then choose an only for prescriptions listed on its formulary, approved primary care provider, who will a list of specific medications in several supervise and coordinate a member's health therapeutic categories. The Alliance formulary care. The primary care provider should:610 does not cover protease inhibitors or z Ensure that care is complete, antiretrovirals, but Alliance members are z Diagnose and treat common illnesses eligible to receive these drugs through and diseases, ADAP.615 z Manage preventative and emergency/urgent care, and Pharmacy Coverage Problems z Refer a member to a specialist when An Alliance member living with HIV/AIDS who also has a mental needed. illness would have to go to two different pharmacies to get Every 30 days a member may choose a medication. The member must go to an ADAP pharmacy for HIV different approved primary care provider. medication and an Alliance pharmacy for other medications. THE DISTRICT’S HEALTH CARE COVERAGEAPPENDIX D: PROGRAMS Members who seek care with a non-Alliance provider are responsible for payment for all services.611 SPECIALTY CARE SERVICES PROVIDED If a member receives care from a specialist The Alliance provides each member with the who is not listed in the Alliance Provider 612 following health care benefits: Directory, the Alliance may cover those z Provider and hospital care when a member services only if the member: (1) receives a is sick or injured; referral from his or her primary care provider, and (2) meets all of the Alliance general z Care to prevent health problems before a requirements discussed above. The Alliance member is sick or injured (for example, will not pay for non-emergency services a preventative care in the form of health member receives from a specialist without a education programs on HIV and STD care referral from his or her primary care provider. and prevention); z Emergency Services; z Urgent care services; z Prescription drugs; RYAN WHITE z Rehabilitation services (physical, occupational, speech therapy); ELIGIBILITY z Dental services; To be eligible for Ryan White funding, individuals or families must be uninsured z Care for special needs (specialty care); and or underinsured and living with HIV/AIDS. z Wellness programs (for example, programs Additional specific requirements for funding to help children stay healthy through vary from state to state as discussed below. regular checkups and preventative care). The Alliance does not cover mental health, BENEFITS alcohol, or substance abuse treatment Ryan White primary outpatient and related services but does cover some psychotropic support services include: drugs. Additional psychotropic drugs that are not covered by the Alliance are available z Physician/clinic visits through the DMH.613 z Prescription drugs (through ADAP)
While the Alliance provides for prescription z Case management drug coverage, actually getting prescription z Home health and hospice care
DC APPLESEED CENTER 129 z Dental care
z Housing and transportation services
z Substance abuse treatment
z Health education, risk reduction
z Outreach
z Insurance continuation.616 Ryan White does not pay for hospitalizations and long-term institutional care.
ENDNOTES 606 Letter from Sally Richardson, Director, Medicaid Bureau, Health Care Financing Administration, Department of Health and Human 599 Financing HIV/AIDS Care, supra note 160, at 7. Services, to State Medicaid Directors (June 19, 1996), available at 600 Kaiser Commission on Medicaid and the Uninsured, MEDICAID http://www.cms.hhs.gov/hiv/hiv61996.asp (last visited RESOURCE BOOK 20 (July 2002), available at July 21, 2005). http://www.kff.org/medicaid/loader.cfm?url=/commonspot/ 607 D.C. Healthcare Alliance, Member Handbook 5 (2002), available at security/getfile.cfm&PageID=14259 (last visited July 21, 2005). http://unityhealthcare.org/PDF's/Alliance/Alliance%20Member%20 601 Id. at 11. Handbook.pdf (last visited July 21, 2005) [hereinafter "Alliance 602 Centers for Medicare & Medicaid Services, Medicaid Eligibility Member Handbook"]. Groups and Less Restrictive Methods of Determining Countable 608 Id. at 7. Income and Resources (May 5, 2001), available at 609 Id. http://www.cms.hhs.gov/medicaid/eligibility/elig0501.pdf (last visited July 21, 2005). 610 Id. at 23. 603 The Personal Responsibility and Work Opportunity Reconciliation 611 Id. at 24. Act of 1996, Pub. L. No. 104-193, 110 Stat. 2105, replaced AFDC 612 Id. at 4. with Temporary Assistance to Needy Families (TANF). 613 D.C. Healthcare Alliance, Drug Formulary 2004, at 3, available at 604 Medical Assistance Administration and HIV AIDS Administration, http://www.chartered-health.com/DCHA/ District of Columbia Department of Health, Operational Protocol for DCHA%20_DRUG_FORMULARY_2004.pdf [hereinafter "Alliance the 1115 HIV Demonstration within the District of Columbia 5 (Oct. Drug Formulary 2004"]. 5, 2004), available at http://www.cms.hhs.gov/medicaid/ 1115/dchivoprprot.pdf (last visited July 21, 2005). 614 Alliance Member Handbook, supra note 607, at 18. 605 Social Security Act, 42 U.S.C. §§ 1396a(a)(10)(A) and 1396d(a) 615 Alliance Drug Formulary 2004, supra note 613. (2003). 616 Financing HIV/AIDS Care, supra note 160, at 12-13.
130 HIV/AIDS IN THE NATION'S CAPITAL ACRONYMS
ACHSP Advisory Committee for HIV and STD Prevention at the CDC ADAP AIDS Drug Assistance Program AHP Advancing HIV/AIDS Prevention AIDS Acquired Immune Deficiency Syndrome APRA Addiction Prevention and Recovery Administration BOP Bureau Of Prisons BSSV Behavioral and Social Science Volunteer Program CARE Comprehensive AIDS Resources Emergency Act CBO Community Based Organization CCHPS Center for Correctional Health and Policy Studies, Inc. CDC Centers for Disease Control and Prevention CMOC Case Management Operating Committee CMS The Centers for Medicare & Medicaid Services CNMC Children’s National Medical Center CPG Community Planning Group CSOSA Court Services Offender Supervision Agency CTF Correctional Treatment Facility CTR Counseling, Testing, and Referral DASH Division of Adolescent School Health DCPS District of Columbia Public Schools DMH Department of Mental Health DOC Department of Corrections DOH Department of Health FMCS Family and Medical Counseling Services, Inc. FPL Federal Poverty Level FSS Federal Supply Schedule GLBT Gay, Lesbian, Bisexual, and Transgender HAA HIV/AIDS Administration HAART Highly Active Antiretroviral Therapy HAB Federal HIV/AIDS Bureau HCSNA Health Care Safety Net Administration HIV Human Immunodeficiency Virus HOPWA Housing Opportunities for Persons with AIDS HRSA Health Resources and Services Administration HUD Department of Housing and Urban Development IDU Injection Drug User IMA Income Maintenance Administration MAA Medical Assistance Administration MOU Memorandum of Understanding MSM Men Having Sex with Men OIG D.C. Office of Inspector General PEMS Program Evaluation and Monitoring System RSAT Residential Substance Abuse Treatment SAMHSA Substance Abuse and Mental Health Services Administration SEP Syringe Exchange Program SSI Supplemental Security Income STD Sexually Transmitted Disease UHU Us Helping Us YRBSS Youth Risk Behavior Surveillance System DC APPLESEED CENTER
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