ALAMEDA COUNTY PUBLIC HEALTH DEPARTMENT OFFICE OF AIDS ADMINISTRATION AND OAKLAND EMA COLLABORATIVE COMMUNITY PLANNING COUNCIL

OAKLAND, CALIFORNIA ELIGIBLE METROPOLITAN AREA 2006 – 2009 COMPREHENSIVE HIV SERVICES PLAN

SUBMITTED TO THE US HEALTH RESOURCES AND SERVICES ADMINISTRATION

DECEMBER 28, 2005 Oakland Eligible Metropolitan Area (EMA) 2006 - 2009 Comprehensive HIV Services Plan

OAKLAND EMA 2006 – 2009 COMPREHENSIVE HIV SERVICES PLAN

TABLE OF CONTENTS

Table of Contents 1

Letter of Concurrence 2

Introduction & Acknowledgments 3

Executive Summary 6

Section I: Where Are We Now? What is Our Current System of Care? 8

Section II: Where Do We Want to Go? What System of Care Do We Want? 46

Section III: How Will We Get There? How Will Our System Need to Change to Assure Availability and Accessibility to Core Services? 47

Section IV: How Will We Monitor Our Progress? How Will We Evaluate Our Progress in Meeting? Our Short and Long-Term Goals? 60

Endnotes 63

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INTRODUCTION & ACKNOWLEDGMENTS

The 2006 - 2009 three-year Comprehensive Plan for HIV service delivery in the Oakland Eligible Metropolitan Area (EMA) is the product of an intensive planning and development process spearheaded by a diverse group of consumers, providers, and HIV specialists from both Alameda and Contra Costa Counties. Together, these individuals worked during the second half of 2005 to chart a course for the future of HIV services in the Oakland EMA that will allow our region to utilize Title I funds to make the greatest possible impact on the continually escalating crisis of HIV and AIDS.

Work on the comprehensive planning process began in early 2005 with an effort by the Services Planning Council of the Oakland EMA Collaborative Community Planning Council to thoroughly evaluate progress made toward goals and objectives contained in the 2002 Comprehensive Plan. Staff of both the Alameda and Contra Costa County AIDS programs prepared a report on progress made and successes achieved in implementing the previous Plan, and summarized ongoing initiatives to put remaining Plan provisions in place. In turn, these documents were utilized by the Services Planning Committee to provide a starting point for development of this year’s new three-year goals, objectives, and action steps.

Beginning in mid-2005, the Oakland EMA Planning Council also formed a Comprehensive Plan Task Force specifically to oversee the development of the three- year Plan. While functioning as an ad hoc subcommittee of the Services Planning Committee, membership on the Task Force was open to all Council members, as well as to interested community members and consumers. Chaired by Sheila Hall, the Task Force met regularly throughout the planning process, including in a special three-hour meeting in September 2005 to develop Plan objectives and action steps.

At the same time, the Planning Council and its Steering Committee reviewed documents produced by the Task Force and approved key components of the Plan. On October 26, for example, the Council reviewed and approved the Plan’s integrated set of three-year objectives. At its meeting of November 30, the Council reviewed and revised the Plan’s three-year action steps designed to aggressively move our EMA forward in continuing to respond effectively to local HIV care needs. And on December 13, the Planning Council Steering Committee met to review and revise the entire Comprehensive Plan document in preparation for submission to HRSA.

The following is a listing of current Planning Council members. The list includes Planning Council members who participated in the Comprehensive Plan Task Force process:

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Oakland Eligible Metropolitan Area Collaborative Community Planning Council

James Taylor, Chair Gale Brown, Vice Chair

Maria Aguilar Paulette Hogan Anthony Shearer Kenneth Arrington Arthur Hollister Bill Stewart Dan Barba Teree Jerome Keith Thompson Amity Balbutin-Burnham AJ King James Walker Maria Camacho Gloria Lockett Norvell Wallace Kathleen Clanon Roosevelt Mosby John Ward Cseneca Greenwood Roy Quintana Hazel Weiss Carla Goad Frederica Robinson Sylvia Young Sheila Hall Joaquin Sanchez Jim Zuber Lorenzo Hinojosa Pauline Sanger

Staff of the Alameda County Office of AIDS participated in the preparation of the Comprehensive Plan document through the submission of progress reports, attendance at Comprehensive Plan Task Force meetings, and review and revision of key Plan sections. The following is a listing of Alameda County AIDS Office staff members:

Alameda County Public Health Department Office of AIDS Administration

Ron Person, Director Lori Williams, Director Care & Prevention Maria Aguilar, Director Data & Quality

LaKisha Brents Venna Doijode Tom Mosmiller Ivory Butler Lorenzo Hinojosa Shelley Stinson Patricia Calloway Deborah Jones Beverly Wayne Dolly Cruse Michael Lee Kimberly Wilson Elenetia DeLeon Al Lugtu

Staff of the Contra Costa County Office of AIDS Administration also provided continual support to the planning process, and helped formulate key Plan sections. Carla Goad of the Office was a dedicated Task Force member. The following is a listing of Office of AIDS Administration staff:

Contra Costa County Health Department AIDS Program

Christine Leivermann, MPH, AIDS Program Director

Carmen Beyer Rhonda Choi Carla Goad

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Marlina Hartley Peter Ordaz

The Contra Costa HIV/AIDS Consortium provides ongoing advice, support, and input to the Contra Costa County Office of AIDS Administration. Consortium members include unaffiliated consumers and representatives of a broad range of local agencies. Consortium members helped provide input into Contra Costa County’s recommendations for the current Comprehensive Plan. The members of the Consortium are as follows:

Contra Costa HIV/AIDS Consortium

Mario Balcita Doris Glasper William Roby Carmen Beyer Robert Hamilton Graciele Salinas Betty Blackmore-Gee Lorena Huerta Sunny Solomon Gale Brown Desiree Jackson Jeri Stegman Mario Camacho Sandra Johnson Corrine Stuart Carlos Carvajal Julie Levin John Sturr Kelly Dunn Margaret Madams Junie Tate Dick Eastwood Cally Martin William Washington Sam Erwin Francisco Nanclares Larry Wilson Alicia Garcia Patrick O’Leary

Staff of All Health Care / Imanis - the Oakland EMA’s contracted Planning Council support agency - provided valuable assistance throughout the planning process. We are grateful to Shirley Manly-Lampkin PhD, RN, Norma Del Toro, Patrice Lee, and Priscilla Banks of All Health for their support. Robert Whirry, an independent Program Development Consultant, provided contracted support throughout the planning process, helping facilitate meetings and preparing successive draft versions of the Plan document.

We are grateful to all of those involved in making the 2006 - 2009 Comprehensive Plan for the Oakland EMA a reality.

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EXECUTIVE SUMMARY

The 2006 - 2009 Oakland EMA Comprehensive HIV Services Plan is designed to serve as a working blueprint to guide the growth and development of HIV/AIDS care and services in Alameda and Contra Costa Counties over the next three years of the HIV epidemic. Developed through a collaborative process involving the local Planning Council and our region’s two County AIDS programs, the Plan offers an assertive, coordinated plan of action designed to improve local HIV outreach, service linkage, and support, while developing effective strategies to better link HIV prevention and care. The Plan is designed to serve as a living document that is continually reviewed, revisited, and improved in order to respond to changing HIV needs and populations, and to incorporate new strategies for improving care and increasing parity of service access.

The need for a thoughtful roadmap to guide the continued development of our local HIV continuum is particularly critical at a time when increasing HIV-infected populations coincide with diminishing financial resources to meet these individuals’ needs. In the Oakland EMA, such financial challenges are particularly daunting given the exploding rates of HIV infection among underserved and hard-to-reach groups such as young gay men of color, transgendered people, active substance users, women, and the homeless - populations that require assertive, coordinated efforts in order to involve and retain them in care. The progress our EMA has made in reducing the percentage of individuals who have an unmet need for HIV medical care is continually being challenged by the growing complexity of newly-diagnosed populations, and the need for evolving systems that can affectively meet the needs of multiply-diagnosed individuals, persons in poverty, and sexual minorities.

A critical step in realizing our goal of a more unified approach to HIV prevention and care was initiated in 2004, when the Oakland EMA began to implement a long- contemplated strategy of merging the region’s HIV service and prevention planning councils into one unified body whose members could work together to address HIV care and prevention needs in a coordinated manner. The process of developing draft bylaws for the merged Planning Council began in August 2004, and the first joint meeting of the newly merged Oakland EMA Collaborative Community Planning Council was held in February 2005.

The newly merged Planning Council represents one of the first such successful efforts ever undertaken in the United States. Thus far, the merger has been extremely effective, with the Council functioning through a joint membership that is fully representative of the HIV epidemic in the Oakland EMA, and that includes a high percentage of both affiliated and unaffiliated consumer members. The group has successfully worked through issues and barriers that have arisen during the transitional period, and has found effective ways to ensure that it professionally accomplishes the twin federal mandates for the role and functioning of both Care and Prevention Planning

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Councils. The Council is looking forward to the development of new and innovative strategies for the coordination and integration of HIV care and prevention services, and for the implementation of new approaches that increase the accessibility, effectiveness, and cost-efficiency of both care and prevention programs.

Despite this important success, however, the challenges facing our regional HIV care system remain profound, and serious decisions are needed in order to continue to improve the effectiveness and impact of local CARE Act-funded resources and programs. Therefore, at the center of our 2006 action plan is a year-long, facilitated strategic planning process involving several full-day meetings to be attended by Council members, consumers, and providers. The goal of this process will be to systematically explore all aspects of both the local HIV care system and the process through which CARE Act funds are prioritized, allocated, and managed in the Oakland EMA, and to make the difficult decisions that are needed to bring about significant enhancements in this system. This process is expected to coincide with the process for addressing changes that may come about through the upcoming Ryan White CARE Act reauthorization.

Our action plan also outlines several key steps designed to increase coordination among the EMA’s two counties; to strengthen training and certification for HIV service providers; and to explore movement toward a continuous needs assessment process for the Oakland EMA. The goals, objectives, and action steps contained in our Plan outline what we believe is an exciting future for HIV care and service delivery in our region - one that gives us our best chance to cope with potential resource reductions while designing an ever-more effective, inclusive, and efficient spectrum of care.

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SECTION I: WHERE ARE WE NOW? WHAT IS OUR CURRENT SYSTEM OF CARE?

A. Description of the Oakland, California Eligible Metropolitan Area

Located east of San Francisco in the Bay Area, the Oakland Eligible Metropolitan Area includes the two counties of Alameda and Contra Costa. The City of Berkeley in Alameda County is its own health jurisdiction, but collaborates with the two counties in EMA-wide planning.

The Oakland EMA is a collection of extremes, encompassing a broad range of ethnicities, economies, and geographies. The total land area of the EMA is 1,458 square miles - an area roughly the size of State of Rhode Island - and encompasses major urban and suburban centers as well as extensive rural areas. The counties are roughly equivalent in land mass (733 square miles for Alameda and 725 square miles for Contra Costa), and the underprivileged in both counties must sometimes travel far distances to several different providers in order to access needed services.

According to the 2000 Census, the total population of the Oakland EMA is 2,392,557, a total representing just over 7% of the total population of the state of California. Alameda County, with a total population of 1,443,741, accounts for 60.3% of the Oakland EMA population, while Contra Costa County, with 948,816 residents, accounts for the remaining 39.7%. The city of Oakland, in Alameda County, is the EMA’s largest city, with a 2000 Census population of 399,484.

The Oakland EMA is one of the most ethnically diverse regions in the nation. The EMA includes a population that is 37% white; 13% African American; 19% Latino/Hispanic; 7% Asian/Pacific Islander; 1% Native American; and 14% multicultural/other ethnic populations. In fact, according to the 2000 Census, Alameda County is the third most ethnically diverse county in the United States. Oakland, Alameda County’s largest city, has a percentage of African Americans that is the second highest in California for places of 100,000 or more1. A total of 46 different languages and dialects are spoken here.

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B. Epidemiological Profile

Summary of the Current Local Epidemic

With 9,290 cumulative AIDS cases diagnosed as of December 31, 2004, the Oakland EMA has the 21st largest number of cumulative diagnosed AIDS cases of any U.S. metropolitan area, and a cumulative AIDS caseload larger than that of 18 U.S. states. Alameda County alone has the 4th highest number of reported AIDS cases by major counties in the State of California for 2005, while Contra Costa County ranks 10th in relation to other counties.2 Oakland also has the 18th highest reported cumulative AIDS caseload out of 107 metropolitan areas listed by the US Centers for Disease Control and Prevention (CDC).3

Between January 1, 2003 and December 31, 2004 alone - the most recent two-year period for which figures are available - a total of 570 new cases of AIDS were diagnosed in the Oakland EMA, according to CDC reports. The ethnic composition of these new AIDS cases was 47.28% Black; 19.33% Hispanic; 3.16% Asian/Pacific Islander; 0.35% Native American; 0.35% multi-racial; and 29.53% White. The percentages of new AIDS cases among people of color are much higher than these populations’ representation within the general population (see Figure 1 below). African Americans in particular are highly disproportionately represented, with new AIDS case rates nearly four times higher than their representation in the overall community.

Figure 1. Comparison of Oakland EMA Ethnicity Percentages - Total Population and AIDS Case Rates

50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% African Latinos Whites Asians / Pacific Native Americans Islanders Americans

Percentage of Total Oakland EMA Population Percentage of People Living with AIDS as of 12/31/04 Percentage of New AIDS Cases - 1/1/03 - 12/31/04

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As of December 31, 2004, the CDC reports that there were 3,666 people living with AIDS (PLWA) in the Oakland EMA. The ethnic / racial composition of this population was 43.44% Black; 13.58% Hispanic; 3.36% Asian/Pacific Islander; 0.36% Native American; 0.16% multi-racial; 39.02% White; and 0.08% Unknown. Of all persons ever diagnosed with AIDS in the target region, 40% are still living with the disease.

Additionally, an estimated 4,5644 persons are believed to be living with HIV but not yet diagnosed with AIDS as of December 31, 2004. The Ethnic composition of this population is estimated to be 44.5% Black; 12.2% Hispanic; 3.7% Asian/Pacific Islander; 0.3% Native American; 0.1% Multi-racial; and 38.1% White. This means that an estimated combined total of 8,230 individuals were living with HIV and/or AIDS in the two counties of the Oakland EMA as of December 31, 2004.5

Ethnicity: As of December 31, 2004, over 54% of cumulative AIDS cases ever diagnosed in the Oakland EMA had been among communities of color, including 40.19% among African Americans; 10.95% among Latinos; 2.58% among Asian/Pacific Islanders; and 0.3% among Native Americans. In comparison, only 42% of cumulative AIDS cases in the entire state of California in 2003 had been among persons of color. From January 1, 2003 to December 31, 2004, over 73% of all new AIDS cases in the EMA occurred within communities of color, despite the fact that people of color make up 63% of the EMA’s total population. Figure 1 above compares the percentages for different ethnicities in the general population to their percentage of PLWA and new AIDS cases in the EMA

Of all communities of color affected by HIV/AIDS in the Oakland EMA, African Americans are by far the hardest hit and the most disproportionately represented, making up only 13% of the EMA’s total population but almost one-half (47.28%) of all persons diagnosed with AIDS between January 1, 2003 and December 31, 2004. African American men and women made up 43.44% of all persons living with AIDS as of December 31, 2004, and were estimated to comprise 45.5% of all those living with HIV as of the same date. Over 3,600 African American men, women, and children were already living with either HIV or AIDS in the Oakland EMA as of December 31, 2004. Meanwhile, Latinos make up just over 13.58% of all people living with AIDS in the Oakland EMA, and over 12.2% of all people estimated to be living with non-AIDS HIV in the two counties. However, Hispanic and Latino AIDS incidence rates have risen sharply over the last three years, a trend which has led to a disproportionate representation within this population.

Gender: As of December 31, 2004, 81.09% of all persons living with AIDS in the Oakland EMA were male, as were 77.6% of all those living with non-AIDS HIV. An estimated 6,515 men were living with either HIV or AIDS in the EMA as of the end of last year, illustrating the continuing crisis of HIV infection among men who have sex with men across all ethnic groups (56.52% of PLWA and 53.7% of people living with HIV (PLWH)). The trends toward higher percentages of HIV and AIDS in the Oakland EMA

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for women also continued in 2004, with 18.91% of all people living with AIDS being women as of the end of 2004, and 25.09% of all new AIDS cases diagnosed between January 1, 2003 and December 31, 2004 occurring among women. The Oakland EMA contains the highest percentage of diagnosed AIDS cases among women of any major metropolitan area in the western United States. In California 8% of all persons living with AIDS as of December 31, 2003 were women; for Los Angeles County the figure was 10.5%; and for San Francisco County the figure was 6.5%; in comparison to the Oakland EMA’s 17.5% representation as of the same date.

While 39% of men living with AIDS at the end of 2004 were African American, 64% of women with AIDS were African American (see Figures 2 & 3). Conversely, 20% of all women living with AIDS and 45% of all males living with AIDS were white. The highly disproportionate incidence of AIDS cases among African American women highlights the deadly magnitude of the HIV/AIDS epidemic within our region’s African American communities.

Figure 2. Men Living with AIDS as Figure 3. Women Living with AIDS of 12/31/04 by Race / Ethnicity as of 12/31/04 by Race / Ethnicity

African Americans (39%) African Americans (64%) Latinos (13%) Latinos (11%) Whites (45%) Whites (20%) Other (3%) Other (4%)

Men having sex with men (MSM) continue to make up the highest proportion of men living with AIDS in the Oakland EMA, constituting 62.35% of all persons living with AIDS in the region with MSM who inject drugs are included. For women, the majority of cases - 56.93% - result from heterosexual transmission. Injection drug use also accounts for a higher percentage of cases among women living with AIDS than among men (31.82% among women versus 18.16% among men). Women also report more “unknown” transmission sources, possibly due to their partners having sex with men or due to undisclosed partner drug use.6

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As of December 31, 2004, almost one out of every four people living with AIDS in the Oakland EMA was a woman, infant, child, or young person. Children and youth alone make up 0.5% of all people living with AIDS in the EMA. The CDC in 2003 listed Oakland as the highest metropolitan area for women, infants, children, and youth living with AIDS as a percentage of all PLWA in the Western US, at 20.8% of the total PLWA population.

A significant proportion of HIV and AIDS cases in the Oakland EMA occurs among transgender persons, a population that traverses a broad spectrum of lifestyles and gender transition stages. A total of at least 21 AIDS cases and 12 HIV cases have been identified among male-to-female transgender persons in Alameda County, while Contra Costa County lists six individuals living with HIV/AIDS as “other/unknown” gender, all of whom are assumed to be transgender individuals. HIV surveillance data reported from the CDC does not track the number of transgender cases at the national or state level, making it difficult to compare local numbers with other regional and national statistics.

Transmission Categories: Men who have Sex with Men, including those who inject drugs (MSM and MSM IDU) continue to make up the highest number of AIDS and HIV cases in the EMA, although the percentages are declining. 62.36% of all adult PLWA and 56.97% of adult PLWH are in this category, accounting for 59% of all adults believed to be living with HIV or AIDS in the Oakland EMA as of December 31, 2004. However, between January 1, 2003 and December 31, 2004, non-IDU MSM accounted for only 46.4% of all new AIDS cases diagnosed during that period, a percentage that is 10% lower than their percentage among the overall population of people living with AIDS.

HIV/AIDS among injection drug users (IDUs) in the Oakland EMA constitutes the largest such epidemic of any EMA in the state of California.7 Fully 17% of all AIDS cases ever diagnosed in the Oakland EMA have occurred among injection drug users, a percentage that is even higher if MSM IDU are accounted for. The epidemics of HIV/AIDS among injection drug users and women in the Oakland EMA are closely interrelated. Women injectors increase their risk by sharing needles and works with others, especially their male partners. Sexual activity with IDUs also contributes to the increase of heterosexual transmission cases among men and women. Sixteen percent of all of men living with AIDS in the Oakland EMA as of December 31, 2004 were heterosexual injection drug users.

Age at Diagnosis: Between January 1, 2003 and December 31, 2004, 63.38% of diagnosed AIDS cases in the Oakland EMA were among persons between the ages of 20 and 44. Two new AIDS cases were among children under 13 years of age, the low number due in large part to increased local provider efforts to identify, test, and support HIV-positive women during pregnancy. Although only one new AIDS case occurred in a young person between 13 and 19 years of age, evidence from AIDS incidence rates points to a rapid spread of HIV among younger populations. For example, while 45.44% of all PLWAs diagnosed with AIDS as of December 31, 2004 were between the ages of

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20 and 44, 63.38% of new AIDS cases diagnosed between January 1, 2003 and December 31, 2004 were within that age range. Conversely, 36.09% of new AIDS cases diagnosed between January 1, 2003 and December 31, 2004 were among persons 45 years or older, although this group still made up 54% of all PLWA in the EMA through the end of 2004.

Future Trends

Concerted efforts to expand and improve HIV education, prevention, testing, and treatment programs in the Oakland EMA have had remarkable success, helping decrease AIDS case rates from a high of 47.6 per 100,000 in 1992 to the present 9.3 cases per 100,000 population in 2004. AIDS Incidence by Race/Ethnicity Unfortunately, this rate is 80% still higher than the State 60% of California’s current rate of 7.8 per 100,000 40% population. The tables to 20% the right summarize AIDS incidence trends 0% Before 1990 1990 1994 2000 2004 within the Oakland EMA over the last 14 years by African American Hispanic White race/ethnicity, gender, and transmission AIDS Incidence by Gender category.8 100%

The regional AIDS 80% epidemic has decreased 60% in the White population 40% but increased year by 20% year among both African Americans and 0% Before 1990 1990 1994 2000 2004 Hispanics. Although Men who have sex with Men Male Female is still the largest transmission category, AIDS Incidence by Exposure Injection Drug Use has 80% continued to increase 60% over the years, and has now been augmented by 40% an upsurge in 20% Heterosexual transmission cases, 0% currently accounting for Before 1990 1990 1994 2000 2004 one-third of all new AIDS MSM IDU MSM & IDU Heteros ex ual

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cases reported in the region in 2004. Women have gone from making up less than 5% of new AIDS cases before 1990 to composing almost 25% of new AIDS cases in 2004, with rapid increases among Hispanic and Latino populations portending future disproportionate rates within this population as well.

C. History of the Local Response to the Epidemic

The Oakland EMA HIV Health Services Planning Council first came into existence in 1994, soon after Alameda and Contra Costa County together became eligible to apply for Ryan White CARE Act funding through Title I. Since its inception, the Planning Council has been responsible for establishing priorities and allocating Title I funds within the Oakland EMA; for ensuring broad information input regarding HIV trends and needs; for involving consumers in HIV-related assessment and decision-making; and for assessing the efficiency of the administrative mechanism in rapidly allocating and effectively monitoring the use of Ryan White CARE Act funds. The Planning Council is also responsible for developing a Comprehensive Plan for the organization and delivery of health services described in Section 2604 of the CARE Act, and participates in the development of the California Statewide Coordinated Statement of Need every three years.

The Planning Council - in collaboration with the Alameda and Contra Costa County AIDS programs - has also helped spearhead the development of a comprehensive, coordinated system of care that has consistently addressed the needs of the most disadvantaged and highest risk populations in our region. This has included a continual prioritization of HRSA-identified core services as lying at the heart of the local system of care, along with funding for additional services that help people with HIV/AIDS achieve stability in their lives in order to maintain health and remain compliant with HIV drug therapies.

By the late 1990s, the escalating crisis of HIV/AIDS among African Americans had become so acute that in November of 1998 the Alameda County Board of Supervisors made the unprecedented decision to declare a State of Emergency in Alameda County directly related to the increasing number and incidence of HIV and AIDS cases within the African American community. This was the first time that a local health emergency related to HIV/AIDS had been declared in any state or municipality, and it reflected the severity and seriousness of the epidemic among African Americans in the Oakland EMA. The declaration immediately resulted in the formation of a local Task Force to strategize solutions to the crisis, and increased national attention on the problem of the African American HIV/AIDS epidemic not only in Alameda County, but nationally. Meanwhile, the seriousness of the injection drug use crisis in Alameda County led to the declaration of a second state of emergency in December 1999 related specifically to the problem of transmission of HIV and Hepatitis B and C through contaminated needles.

Beginning in late 2004, the Oakland EMA began to implement a long-contemplated strategy of merging the region’s HIV service and prevention planning councils into one

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unified body whose members could work together to address HIV care and prevention needs in a coordinated manner, and to develop new and innovative strategies for integrating HIV care and prevention programs, particularly in light of the growing national attention being placed on prevention with positives programs. The process of developing draft bylaws for the merged Planning Council began in August 2004, with a hired consultant working in conjunction with representatives of both the HIV Health Services Planning Council and the HIV Prevention Planning Council. These bylaws were approved in early 2005, and the first joint meeting of the newly merged Oakland EMA Collaborative Community Planning Council was held in February 2005.

The newly merged Planning Council represents one of the first such successful efforts ever undertaken in the United States. Thus far, the merger has been extremely effective, with the Council functioning through a joint membership that is fully representative of the HIV epidemic in the Oakland EMA, and that includes a high percentage of both affiliated and unaffiliated consumer members. The group has successfully worked through issues and barriers that have arisen during 2005, and has found effective ways to ensure that it professionally accomplishes the twin federal mandates for the role and functioning of both Care and Prevention Planning Councils. The Council is looking forward to the development of new and innovative strategies for the coordination and integration of HIV care and prevention services, and for the implementation of new approaches that increase the accessibility, effectiveness, and cost-efficiency of both care and prevention programs.

D. Assessment of Need

HIV Care and Service Needs

The HIV/AIDS epidemic in the Oakland EMA is a critical health emergency that significantly impacts the quality and length of life for men, women, and children living in our region, and which continues to affect a much higher proportion of low-income men and women who lack access to basic health services than in other areas of California. In Alameda County, this disproportionate impact is related in large part to the epidemic’s impact on communities of color, especially upon African American and Latino communities, as well as on low-income women and children. In Contra Costa County, the disproportionate impact relates to the prevalence of the epidemic among both injection drug users and African American communities, including women, children, and homeless populations. In both counties, the epidemic also places severe pressure on underserved communities of gay young men of color and transgender people. The HIV/AIDS epidemic in our EMA targets the most underprivileged, underserved, and under-recognized populations in our region - individuals who face the most daunting range of personal and economic barriers to accessing and maintaining care. While the Oakland EMA does not contain the nation’s largest number of HIV/AIDS cases, it has been disproportionately devastated by the AIDS epidemic because of the degree to which the epidemic is impacting those populations who are least able to afford or access care, and who are precisely the most difficult and costly to reach and to serve.

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The HIV/AIDS epidemic in the Oakland EMA can only be properly understood as part of an interrelated series of epidemics rooted in the deeper underlying problems of poverty, racism, and economic and social disparity that characterize many parts of our service region. These epidemics - both social and health-related in nature - challenge the EMA to provide specialized HIV/AIDS services, while working with other disciplines to address the deeper causes that underlie these problems. In terms of HIV and AIDS, the epidemic’s co-morbidities serve both as indicators of the potential growth in the epidemic’s scale and impact, and as symptoms of the far deeper and more prevalent problems which the Oakland EMA has worked for many years to overcome.

Sexually Transmitted Diseases (STDs), for example, play a critical role in HIV transmission and other diseases such as Hepatitis. The Oakland EMA had an average of 53 new primary, secondary, and early latent syphilis cases reported each year between 2001-2003 (2.2 per 100,000 population) and an average of 7,383 annual cases of Chlamydia (308.58 per 100,000) over the same time period.9 Alameda County’s average 2001-2003 Chlamydia incidence rate of 331.57 cases per 100,000 ranks it as the county with the eleventh highest incidence in California, with Contra Costa County not far behind with 247.46 cases per 100,000. The EMA also copes with extremely high rates of gonorrhea. With 2,559 new gonorrhea cases reported in 2004 alone, and a rate of 107 per 100,000, this is above the California case rate of 82.7.10

Other diseases such as tuberculosis (TB) are more easily transmitted in the environments in which poor, homeless, and substance using individuals find themselves. An average of 285 new cases of Tuberculosis were diagnosed each year in the Oakland EMA between 2001 and 2003, for a total incidence of 11.9 per 100,000 population - a rate significantly higher than the California statewide incidence of 9.8 cases per 100,000. The average 144 new TB cases reported in Alameda County in 2004 gives Alameda County the third highest TB incidence rate of any county in California.11

Hepatitis C is also highly prevalent in the Oakland EMA, with estimates of 28,000 Hepatitis C infected residents in Alameda County12 and an even larger number in Contra Costa. New HCV cases are closely related to injection drug use through the sharing of needles, syringes, and other drug paraphernalia. One Public Health Department pilot HCV testing program conducted at HIV test sites in Alameda County in 2001-02 found an overall HCV positivity rate of 40%, with one local needle exchange site having a 70% HCV rate and with Highland Hospital having a positivity rate of 35%. Studies of methadone clients show that over 96% have seroconverted within 5 years of beginning their injection drug use. A Hepatitis B and C prevalence study of Street- Recruited IDUs by the Urban Health Study in our EMA found that 75% of individuals tested had antibodies to HBV and 89% tested positive for antibody to HCV in 200113. And a study conducted by the University of California San Francisco found that low- income women in San Francisco and Alameda County were infected with Hepatitis C at double the national average, with the same study also reporting a link to non-injection

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drug use such as cocaine snorting, as well as the co-morbidity of herpes, the lesions of which increase the likelihood of infection from other diseases14.

Other co-morbidities in the Oakland EMA with far-reaching implications include the ongoing local epidemics of substance use, poverty, and homelessness. While struggling with their addiction, substance users are far less likely to attend to basic healthcare needs, and often present at emergency rooms with advanced ailments such as abscesses, blood poisoning, and AIDS. Diagnosis in late stages of HIV infection means increased costs of medical care and limited benefits from the anti-retroviral drug therapies. It is currently estimated that at least 35,724 men, women, and young people over the age of 18 in the Oakland EMA are already active injection drug users, and every one of them is at extreme risk for HIV and HCV infection.15

Other drugs of abuse, such as crack, heroin, and methamphetamine, impair health and put people at risk due to crime, increased risky sexual and drug using behaviors, as well as place a heavy toll on the addicts’ family and friends. Between 1999-2001 - the last period for which full statistics are available - there was an average of 18,288 adult arrests each year for drug violations in the Oakland EMA, as well as 10,905 annual adult arrests for alcohol violations and 2,021 annual juvenile arrests for alcohol and drug offenses. In addition, an average of over 585 men and women died in the EMA each year as result of alcohol and drug use between 1999-2001.16

The threat of homelessness remains an ominous and continual fact of life in the Oakland EMA for most low-income persons living with HIV and AIDS. According to a recent report by the National Low Income Housing Coalition, both Alameda and Contra Costa County rank among the seven least affordable counties in the entire United States in terms of costs of rental housing.17 Because of the high costs of housing and low vacancy rates in the two counties, on any given night it is estimated that 15,000 individuals are homeless on the streets of the Oakland EMA, a rate of 626.9 per 100,000 population. Over the course of a given year, an estimated 42,000 men, women, and children will find themselves without an adequate place to find shelter.18 The Contra Costa County HIV/AIDS Housing Survey, conducted in late 1995 among persons living with HIV throughout the county, found that 31% of respondents had experienced homelessness since learning of their HIV status; 35% of respondents had experienced at least one episode of homelessness within the past five years; and 4% of respondents were currently homeless, living on the streets or in cars, abandoned buildings, or shelters. In addition, the California Comprehensive Housing Assistance Plan estimates that 25% to 30% of the state’s homeless suffer from severe mental illness, while the Contra Costa County Drug and Alcohol Needs Assessment estimates that between 23% and 40% of the homeless population abuses drugs or alcohol. Another 5% to 10% of California’s homeless population is estimated to be runaway youth, according to the Comprehensive Housing Assistance Plan.19

The problem of homelessness is closely linked to that of poverty, which presents an even more daunting challenge for those who care for HIV-affected populations in this

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region. Using 2000 Census data, we estimate that 35.9% of the Oakland EMA population is currently living at 300% of Federal Poverty Level or below, which translates to an estimated total of 858,902 individuals lacking resources to cover all but the most basic expenses. In the Contra Costa cities of Richmond and San Pablo, more than 50% of all persons live below Federal Poverty Level, and in over half of the census tracts in Contra Costa County, children comprise between 33% and 49% of all people in poverty. At the same time, an estimated 14.61% of those in the Oakland EMA are currently estimated to be without any form of insurance coverage - including Medicaid - for a total of 349,636 uninsured individuals in our region.20 According to a recent report, an estimated 77% of those who are uninsured in Alameda County are people of color.21 Unemployment has also been on the rise in the Oakland EMA, reaching 5.2% in Alameda County and 4.8% in Contra Costa County as of August 2005, figures that translate into at least 65,000 unemployed individuals in the two counties.22

Unmet Needs Estimate

The Oakland EMA utilizes the HRSA Unmet Needs Framework to estimate the total number of individuals with unmet HIV care needs living in our two-county region. During 2005, these estimates were prepared in collaboration with the California Department of Health Services, which worked with each of California’s nine Title I EMAs to estimate the number of persons who were living with HIV or AIDS, were aware of their status, and had received HIV primary care in FY 2003-2004. HIV primary care (met need) was operationalized as receipt of viral load (VL), CD4 count, or anti-retroviral therapy (ART) during the time period of 07/2003 – 06/2004. Of the 8,127 people estimated to be living with HIV/AIDS in the EMA jurisdiction, it is estimated that 4,916 (61.7%) received HIV primary medical care during the specified time period, while 3,111 (38.3%) demonstrated an unmet need for HIV primary medical care. Among the 4,347 people living with AIDS during the specified time period, 2,825 (65%) showed evidence of receiving primary medical care, while 1,522 (35.0%) had an unmet need in regard to primary medical care. Meanwhile, among the 3,780 people living with non-AIDS-diagnosed HIV in the EMA during the same time period, 2,191 (58%) had received HIV primary medical care at some point during the period, while 1,589 (42.0%) had an unmet need in these areas. The combined population of people living with AIDS and HIV who have an unmet need in the Oakland EMA are predominantly male (73.6%), over 40 years of age (71.8%), and primarily African American (38.7%) or White (34.9%). Demographic characteristics for these populations are described in Figure 4 below. Of the total number of people living with AIDS in the Oakland EMA who had an unmet need for HIV medical care, Alameda County had 76.1% of this total population and Contra Costa County had 23.9% of the population. Of all persons living with non-AIDS HIV in the EMA, 73.7% resided in Alameda County and 26.3% resided in Contra Costa County.

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Figure 4. Demographic Characteristics of Combined PLWA and PLWA Cases in the Oakland EMA

Out of Care (Unmet Need) In Care (Need Met) AIDS HIV Total AIDS HIV Total Gender Female 14.7% 37.6% 26.4% 19.8% 25.4% 22.2% Male 85.3% 62.4% 73.6% 80.2% 74.6% 77.8% Age Group 0-12 yrs 0.1% 2.8% 1.4% 0.2% 0.5% 0.4% 13-19 yrs 0.2% 2.4% 1.3% 0.4% 1.1% 0.7% 20-29 yrs 1.6% 10.8% 6.3% 2.2% 6.2% 3.9% 30-39 yrs 17.4% 20.9% 19.2% 18.9% 23.1% 20.8% 40-49 yrs 41.5% 31.5% 36.4% 43.5% 36.9% 40.6% 50& over 39.2% 31.6% 35.4% 34.8% 32.1% 33.6% Race/Ethnicity Asian/PI 3.2% 6.4% 4.8% 3.2% 5.0% 4.0% Black 36.9% 40.5% 38.7% 44.0% 42.9% 43.5% Hispanic 10.5% 8.9% 9.7% 14.3% 11.3% 13.0% Native Am/Alaskan 0.2% 0.4% 0.3% 0.4% 0.3% 0.3% White 41.4% 28.7% 34.9% 36.8% 34.1% 35.6% Other/Unknown 7.8% 15.2% 11.5% 1.3% 6.3% 3.5%

Total 1522 1589 3111 2825 2191 5016

In addition to the above unmet needs statistical data, a 2005 analysis of clients in care in the Oakland EMA shows that Title I/II funded programs in the EMA are serving populations most in need of subsidized medical and social service care. The system is serving a higher proportion of Blacks, Hispanics, Women and Heterosexuals - individuals from populations with increasing AIDS rates and those who are known to have problems accessing and maintaining service contact. For example, while 44% of those living with combined HIV/AIDS in the Oakland EMA as of December 31, 2004 are African American, 52.7% of those served through Title I programs over the 12 months period have been African American. Similarly, while 22.4% of all those living with HIV in the Oakland EMA are women, 26.8% of those served through the local Ryan White system are women. The EMA’s system also serves a higher percentage of heterosexually infected individuals (31.8%) than in the overall HIV-infected population

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(20.4%). Hispanics are also being served higher (16.7%) than their proportion of infected people in the EMA (12.2%).

Gaps in Care

The Oakland EMA undertook a Needs Assessment in 2004-05.23 The most significant finding resulting from that assessment centered on the fact that in 15 separate service categories, at least 20% of participants said that they needed more access to that service than they were able to obtain, or indicated barriers to accessing those services. For example, 16% of respondents stated that they needed more Primary Care services than what they received and 25% indicated they needed more Case Management; 34% stated they needed more Dental services; Emergency Financial Assistance was cited by 32%; Food Vouchers 29%; Food and Household Items 25%; Transportation 23%; Housing Assistance 25%; and Therapy and Counseling 20%. Interestingly, over 61% said they did not need substance abuse treatment services, and only 10% said they needed more than what was available. Very few felt they would need these services in the future. This is counter to what providers say they know of their clients’ habits, with some medical providers estimating that over 60% of their clients have substance abuse issues, especially polydrug use.

Prevention Needs

Consistent, personalized, and assertive HIV prevention education and support for persons living with HIV and AIDS is an indispensable component in the continuum of effective HIV care. Creating strong linkages between HIV prevention and care helps defer new cases of HIV; ensures rapid identification of new HIV infections; and can immediately link newly-diagnosed HIV-positive individuals to the HIV care system, in turn greatly increasing their chances of accessing and remaining on combination therapies. At the same time, HIV prevention programs for HIV-positive persons can reduce new cases of HIV infection while helping reinforce stable lifestyles and self- protective behaviors. The US Centers for Disease Control and Prevention’s Advancing HIV Prevention (AHP) Initiative highlights prevention with positives as the third of the initiative’s four central strategies, stressing the importance of prevention with positives programs in reaching those who have been diagnosed with HIV but are not in care, and emphasizing the need to develop standardized procedures for prevention interventions for persons living with HIV.24

The February 2005 merger of the Oakland EMA HIV Services and HIV Prevention Planning Councils represents a groundbreaking statement of commitment by our region in support of the notion that HIV prevention and care must be better and more effectively linked, integrated, and coordinated. The merger reflects the strong belief that HIV prevention and care can no longer be effectively treated as separated areas, but rather must be viewed as inextricable components which make up a larger vision of HIV intervention that begins at the first moment of personal HIV risk and continues through the full spectrum of HIV care and support.

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The new merged Planning Council will allow our region to develop a broad range of innovative approaches to better linking HIV prevention and care, including creating more assertive prevention outreach initiatives directed toward hard-to-reach and underserved communities such as young gay men of color and transgender populations - interventions which we hope will lead to greater numbers HIV-infected youth and adults being identified and linked to care at the earliest possible stage in their infection. Our efforts will also be focused on expanding the quality and availability of prevention with positives services within HIV treatment and support organizations, including applying the expertise of HIV prevention specialists to the HIV-positive population through training, support, and program development collaborations throughout the EMA.

It is our hope that the new local merged Planning Council will eventually be seen as a major step forward in helping providing the kind of leadership that will eventually help other EMAs to better and more effectively link and integrate HIV prevention and care programs at all levels.

E. Description of the Current Continuum of Care

The Oakland EMA is composed of Alameda and Contra Costa Counties. Each Health Department is responsible for the health needs of its populace. A third health jurisdiction, the City of Berkeley, is within Alameda County but includes its own health department. Alameda County (the Grantee) and Contra Costa County (the Subcontractor) have an Intergovernmental Agreement specifying the details of their working relationship in accordance with HRSA regulations, including that up to 5% of local Title I funds may be expended for administration of the program by the Office of AIDS and up to 5% for Quality Assurance activities. Remaining funds are allotted by the Planning Council as per HRSA regulations, with proportional allocation of Ryan White Title I and MAI funds based on the number of AIDS cases reported as of December 31 of the previous year by the State of California Department of Health and Human Services. The Title I Grantee Agency for the Oakland EMA is the Alameda County Health Care Services Agency and its Office of AIDS Administration (OAA). The Title I funds in Contra Costa County are administered through the Contra Costa County Department of Health Services AIDS Program.

The chart on the following page outlines the current Continuum of Care design for HIV services in the Oakland Eligible Metropolitan Area.

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Oakland EMA Continuum of Care

SUPPORT SERVICES Client Advocacy Transportation

Health Education OTHER HEALTH &Case CARE SERVICES Housing Management Risk Reduction Clinical Research Advocacy & Food ESSENTIAL SERVICES Out of Care Housing Primary Outreach Assistance Health Care Primary Medical Care Legal Services Substance Abuse Treatment Emergency Financial Mental Health Services Treatment Adherence Assistance Oral Health Case Management Services HIV Related Medications Alternative Treatment Vision Care Nutritional Hospice Services Home Health Care Day or Respite Child Welfare Services Services Translation Emotional Support

Access Services

- Case Management - HIV Testing & Counseling - Medical Programs - Information and Referral - Early Intervention Services - Outreach, Education and Prevention

Although the Oakland EMA consists of three separate health jurisdictions, the region’s Continuum of Care framework enables providers, health departments, and the community to meet the continuing and changing needs of people living with HIV/AIDS in any area of the EMA in order to increase access to services and decrease disparities to people disproportionately affected by HIV (HRSA’s goal). The overarching goal of the EMA-wide system is to ensure that all people living with HIV or AIDS are enrolled in a primary medical care program. Alameda County relies on a system of public and private hospitals, numerous community health clinics and private physicians linked through Titles I, II, III, and IV funding and provider networks. Every year, more than 20 agencies are funded by Titles I/II to provide a wide array of services. Additionally, over 40 more agencies in Alameda County are linked to these providers by referral systems and collaborate through long-standing provider networks. In Contra Costa County the County Health system, through its Basic Health Care plan, provides primary medical care and other health services to PLWH/A who are low-income or indigent.

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Approximately seven agencies are funded per year to provide Core Services and a variety of other HIV related services.

The components of the region’s Continuum of Care consist of the following:

Essential Services: Core HIV Services that all PLWH/A should have access, including medical care, mental health, substance abuse treatment, case management, oral health care, and medications;

Other Health and Care Services: The wide range of medical and additional programs that address basic living needs for enhanced survival;

Support Services: Ancillary or “wrap-around” services which are necessary for the infected population to manage their illness with supportive programs; and

Access Services: Gateways into the system of care from a variety of HIV and non- HIV services in the community.

The intent of the Continuum of Care is the provision of seamless services from first contact through all levels of medical, social service and support services as well as inter-entity coordination within the EMA. Between the three health jurisdictions and all service providers, this goal is accomplished through shared values and beliefs, common practices and procedures, and mutual participation on the regional Planning Council, its committees, and its annual prioritization and allocations process.

One important step that has produced greater integration and coordination throughout the EMA has been the recent merging of the Education and Prevention Council with the Ryan White Care and Treatment Council into the Collaborative Community Planning Council. Council members now represent a continuum of HIV/AIDS services including primary and secondary prevention; outreach to at-risk populations; HIV Testing, Counseling and Referral; health education and risk reduction; medical and social services; and support services to assure access to care.

Access Services listed above include those providing initial entry to services as well as those providing ongoing access and retention in primary medical care. HIV Testing programs are used to find unknown cases of HIV and channel these clients into care as well as link to Partner, Counseling and Referral Services (PCRS). The three health jurisdictions operate and/or fund anonymous and confidential HIV testing sites. These are often located in community health or STD clinics, drug treatment programs, as well as available in communities frequented by high-risk populations such as men who have sex with men, injection drug users and sex workers. For example, the NIGHT (Neighborhood Intervention Geared at High Risk Testing) program uses street outreach and mobile clinics to reach high-risk groups, such as injection drug users (testing at needle exchange sites), sex workers, and young gay men of color. Four high test volume agencies have begun offering Rapid Testing, as well as routine oral specimen

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testing. Spanish speaking counselors are available at select sites. Testing providers follow distinct protocols for ensuring that people receiving positive test results are referred to appropriate services, frequently accompanying clients to their first medical or case management appointment. Several sites also offer free HCV testing and Partner Counseling and Referral.

Key to accessing care for those knowing their status but not presently in the system of HIV/AIDS primary care is to break down barriers from the very beginning. Agencies conducting Outreach, HIV testing, and peer community support believe that the best approach towards prospective clients is one that is culturally and linguistically appropriate and always respectful of a person’s lifestyle choices. Staff members are generally from the at-risk communities themselves and know areas of high-risk behaviors. The Oakland EMA Continuum of Care allows providers at every point along the service spectrum to make qualified client referrals to primary care based on individual client needs and preferences. Once clients enter the system, they are free to move among different levels of service based upon immediate and emerging needs, including moving freely among the EMA’s three health jurisdictions. The EMA prides itself on the variety of services that are peer driven and provide outreach support, all with the intent of trying to retain people in care, including: Syringe Exchange sites; homeless programs; street outreach for sex workers and substance abusers; youth focused testing and referral programs; bilingual (Spanish) HIV education, street outreach, and support groups; and programs in African American communities.

Local Title I and MAI programs endeavor to 1) remove barriers to accessing care; 2) be comprehensive in their linkages and referrals to services within the continuum and 3) be culturally and linguistically appropriate to diverse populations. Our MAI programs target African American and Hispanic populations either 1) in transitional support programs for people recently released from incarceration, including case management, short term housing, substance abuse counseling, and treatment adherence services (Alameda County); or 2) through outreach and case management for multiply diagnosed HIV-positive people of color who had been out of care (Contra Costa).

Case Management in the Oakland EMA is a client-centered service that endeavors to engage the person in the promotion of their own health and well being through assessment, service planning, linkage to appropriate levels of health and support services, monitoring and regular assessment of the care plan. Community-based Psychosocial Case Managers provide services to individuals who are in need of supportive services, but who do not require intensive medical support; Medical (Nurse) Case Management is provided to individuals who have been or are seriously ill, and is delivered by a team of a nurse case manager and a medical social worker.

In Alameda County, clients frequently enter the Continuum of Care by accessing primary and emergency medical services through HIV counseling and testing sites, hotline referrals, and through substance abuse and mental health treatment programs. There are five subcontracted Title I/II agencies for case management. However, other

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CBOs have case management for clients with specific to HIV/AIDS needs. For example, the Family Care Network Title IV supports clinic based case managers at hospitals; Alameda County Alcohol and Drug Programs supports an HIV case manager at East Bay Community Recovery Project; and Alameda County Health Services supports a Nurse Case Management Program. In Contra Costa County, an HIV Intake Coordinator serves as a centralized source of information for providers and HIV-positive people in the County, referring clients countywide to case management services that may be at CBOs or at the County Nurse Case Management program.

Case Management Programs have facilitated access to primary medical care and other core and related HIV/AIDS services by lessening or alleviating some of the underlying conditions which hinder successful follow-through, such as mental health and substance abuse issues, homelessness and poverty. For example, besides the usual case management services of benefits and housing referrals, the AIDS Project East Bay case management program has added psychotherapy services from an African American psychiatrist experienced in the treatment of mental disorders and related issues of people of color. All the EMA case management programs have extensive linkages to programs in the full spectrum of the Continuum of Care that are formalized by MOUs, team meetings, and consultations.

F. Resource Inventory and G. Profile of Ryan White CARE Act Funded Providers

The chart on the following pages provides a summary and overview of the major HIV/AIDS care providers in the Oakland Eligible Metropolitan Area. The list includes public and governmental agencies helping oversee HIV services in the two-county region; HIV/AIDS-specific service organizations providing general and specialized HIV care, treatment, and support services; and a range of public and private supportive organizations offering one or more key services that help complete the chain of comprehensive care in our region. Agencies receiving Title I funds to provide direct HIV care and services are indicated by a checkmark in the second-to-right column. Agencies receiving support from other CARE Act sources – including through Titles II, III, IV, AETC, and HOPWA – are indicated with a checkmark in the far right column.

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INVENTORY OF OAKLAND EMA HIV SERVICES AND RESOURCES

Other Agency CARE Phone/Web Site Services Provided Title I Name/Address Act Funds 14th Street Clinic and 510-333-0700 Substance abuse services Medical Group including psychological testing 1124 International Blvd. and evaluation, detox, psychiatric √ Oakland, CA 94621 services, AIDS services including HIV testing and counseling. Affordable Housing 510-538-7537 Acquires, builds, rehabilitates Associates www.ahainc.org housing for low-income persons, 1250 Addison St., Ste. including those with HIV/AIDS G diagnosis. Berkeley, CA 94702 African American 510-588-5900 HIV education and prevention; AIDS Support www.amassi.org transitional housing; substance Services and Survival abuse relapse prevention; Institute, Inc. treatment advocacy and AIDS 222 14th Street, 2nd drug assistance program; youth Floor transitional housing for sexually Oakland, CA 94612 diverse and HIV-positive youth. AIDS Clinical Trials 800-874-2572 Central resource providing Information Service www.actis.org information on federally and PO Box 6421 privately sponsored clinical trials Rockville, MD 20849- for AIDS patients and HIV- 6421 infected individuals. AIDS Healthcare 510-628-0949 HIV prevention and advocacy, Foundation Earvin www.aidshealth.org healthcare, access to specialists, “Magic” Johnson Jr. medications, treatment and Clinic services. √ 411 30th St., Ste. 200 Oakland, CA 94609 AIDS Legal Referral 510-451-5353 Legal assistance for persons with Panel (at AIDS Project HIV/AIDS including insurance of the East Bay) disputes, housing issues, 1755 Broadway St., 2nd guardianships and wills, Floor advocacy for disability benefits. Oakland, CA 94612

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Other Agency CARE Phone/Web Site Services Provided Title I Name/Address Act Funds AIDS Project of the 510-663-7979 HIV education and advocacy; East Bay (APEB) www.apeb.org emergency services for food, 1755 Broadway St., 2nd housing, utilities; access to Floor counseling, crisis intervention, √ √ Oakland, CA 94612 support groups. Wellness Center provides primary care to adults living with HIV/AIDS. Alameda County 510-667-3201 Comprehensive inpatient and Health Care Services www.fairmonthlyservi outpatient AIDS services, Agency ces.org including case management, Alameda County palliative care/hospice, Medical Center investigative drug therapies, √ √ Fairmont Campus alternative therapies, AIDS Drug HIV Services Assistance Program, voicemail 15400 Foothill Blvd. program for homeless clients. San Leandro, CA 94578 Alameda County 510-437-4800 Acute inpatient and outpatient Health Care Services www.acmedctr.org/hig medical care. Adult Immunology Agency Alameda hland.htm Clinic for AIDS patients offers County Medical comprehensive services. AIDS Center Highland Drug Assistance Program. HIV √ √ Campus testing. 1411 E 31st St. Oakland, CA 94602 Alameda County 510-267-3240 Collects and analyzes data Health Care Services related to HIV/AIDS and Agency Public Health maintains registry of AIDS cases Department AIDS and in Alameda County. Communicable Disease Division √ AIDS Epidemiology Surveillance Unit 1000 Broadway, Ste. 500 Oakland, CA 94607 Alameda County 510-873-6500 Contracts with community-based Health Care Services organizations and county Agency Public Health agencies to deliver support Department Office of services for persons with HIV AIDS Administration infection and their families, √ √ 1970 Broadway, Ste. friends and caregivers. Oversees 1130 administration of the Ryan White Oakland, CA 94612 Title I grant for the Oakland EMA.

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Other Agency CARE Phone/Web Site Services Provided Title I Name/Address Act Funds Alameda County 510-533-4663 Permanent housing and support Health Care Services services for eligible homeless Agency Public Health families, including alcohol and Community Health drug counseling, HIV education Services Division and prevention. Health Care for the Homeless Oakland Homeless Families Program 1900 Fruitvale Ave., Ste. 3D Oakland, CA 94601 Alameda County 510-281-7700 Self help program offering Network of Mental housing and employment Health Clients assistance for verifiably Oakland diagnosed mentally ill clients; HIV Independence support/education; HIV testing. Support Center 518 18th St. Oakland, CA 94612 Alameda Emergency 510-523-5850 Distribution of free food for needy Food Bank www.alamedafoodban persons. PO Box 2167 k.org Alameda, CA 94501 Alameda Health 510-769-2243 ACCESS program supports a Consortium consortium of Title III-funded 1230 Harbor Bay direct medical clinics. Dental Parkway # 250 Care Program provides free √ √ Alameda, CA 94610 confidential dental care to low- income, uninsured persons with HIV. Allen Temple Baptist 510-544-8910 Case management, education Church www.allen-temple.org and support services for persons Allen Temple AIDS with HIV and their families. Ministry 8501 International Blvd. Oakland, CA 94621

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Other Agency CARE Phone/Web Site Services Provided Title I Name/Address Act Funds Ark of Refuge, Inc. 510-382-9166 Case management services HIV Programs Case www.arkofrefuge.org including psychosocial case Management Services management, rental subsidy, 8715 International direct emergency assistance to √ Blvd., Room 5 persons with HIV/AIDS. Oakland, CA 94621 Ark of Refuge, Inc. 510-635-8422 Emergency and long-term HIV Programs Walker www.arkofrefuge.org supportive housing for persons House with symptomatic HIV/AIDS. √ 9702 International Blvd. Oakland, CA 94603 Asian Health Services 510-986-6830 HIV testing; early intervention 818 Webster St. wwws.ahschc.org care for persons with HIV; Oakland, CA 94607- education and outreach; AIDS √ √ 4220 Drug Assistance Program. Bay Area Addiction 510-232-0874 Outpatient detoxification and Research and (Richmond) methadone maintenance. AIDS Treatment (BAART) 925-427-2285 services include HIV testing, pre 1313 Cutting Blvd (Antioch) and post-test counseling, Richmond, CA 94804 www.baartcdp.com information and referral, and education and prevention and 3707 Sunset Lane support groups. Antioch, CA 94509 Bay Area Black 510-763-1872 Comprehensive assistance to Consortium for www.babcqhc.org persons diagnosed with disabling Quality Health Care, HIV/AIDS; food pantry; case Inc. AIDS Minority management; AIDS education; Health Initiative crisis intervention; counseling; √ (AMHI) referrals for housing. 1440 Broadway, Ste. 209 Oakland, CA 94612 Bay Area Young 415-487-1616 Peer-based support for young Positives www.baypositives.org people (ages 26 and under) living 518 Waller St. with HIV. Case management, San Francisco, CA peer counseling, acupuncture, 94117 massage. Berkeley Addiction 510-644-0200 Non-residential services to heroin Treatment Services users, including counseling, 2975 Sacramento St. medical and social services. √ Berkeley, CA 94702 Methadone maintenance.

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Other Agency CARE Phone/Web Site Services Provided Title I Name/Address Act Funds Berkeley Community 510-548-2715 Community-based health center Health Project www.berkeleyfreeclini offering same day appointments Berkeley Free Clinic c.org for medical care; dental clinic; 2339 Durant Ave. STD testing including HIV; peer Berkeley, CA 94704 counseling, referrals, condoms and bleach; women’s and men’s clinics. Berkeley Emergency 510-649-4965 Assistance to homeless and Food and Housing hungry persons. Emergency Project shelter, drop-in center, 2855 Telegraph Ave. transitional housing for women Berkeley, CA 94704 with HIV. Berkeley Housing 510-644-4840 Subsidized rental housing for low- Authority www.ci.berkeley.ca.us income persons. 1901 Fairview St. Berkeley, CA 94703 Berkeley Women’s 510-843-6194 Preventative medical services, Health Center basic gynecological services, 2908 Ellsworth St. general medical care. HIV high- Berkeley, CA 94705 risk assessment and education. Bi-Bett Corporation 510-568-2432 A community recovery center for East Bay Recovery substance abusers and their Center families. 10700 McArthur Blvd., Ste. 12 Oakland, CA 94612 Bi-Bett Corporation 925-676-4840 Social model recovery home for Frederic Ozanam alcoholic and drug-addicted Center women. 2931 Prospect Ave. Concord, CA 94520 Brookside Community 510-215-9092 Primary and dental care to Health Center persons of all ages, including 2023 Vale Rd., Ste. 107 testing and treatment of sexually San Pablo, CA 94806 transmitted infections, health education. Building 510-649-1930 Multiple centers dedicated to Opportunities for Self- www.self- helping poor, homeless and Sufficiency (BOSS) sufficiency.org disabled persons achieve health 2065 Kittredge St., Ste. and self-sufficiency. Includes E residential housing for persons Berkeley, CA 94704 with HIV/AIDS.

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Other Agency CARE Phone/Web Site Services Provided Title I Name/Address Act Funds California Prostitute 510-874-7850 HIV/AIDS and drug use education Education Project www.calpep.org and prevention for prostitutes, (CAL-PEP) sex workers, IV drug and crack 1755 Broadway, 5th users, homeless persons and Floor runaways. Condom and bleach Oakland, CA 94612 distribution; support groups; AIDS Drug Assistance Program; speakers bureau; HIV testing. Catholic Charities of 510-768-3100 Education, prevention and case the East Bay Diocese www.cceb.org management to persons with of Oakland HIV/AIDS HIV/AIDS and their families. Services Housing advocacy; PLWA √ √ 433 Jefferson St. residence; substance abuse Oakland, CA 94607 counseling; workshops; speakers bureau. The Center 510-655-3435 Support services for persons with (formerly Center for www.thecenteroaklan HIV/AIDS including day center AIDS Services) d.org providing meals, recreational 5720 Shattuck Ave. activities, support groups, case Oakland, CA 94609 management, counseling, √ transportation services, and emergency services for food, housing, utilities. Center for Human (925) 687-8844 Prevention education program Development www.chd- serving children, youth, 391 Taylor Boulevard, prevention.org individuals and families in the Bay Suite 120 Area. Queer Youth Action Team Pleasant Hill, provides youth advocacy group CA 94523 promoting awareness and decreasing homophobia and the risk of HIV among lesbian, gay, bisexual, transgender and questioning youth in Contra Costa County schools. Child Health Disability 925-313-6150 A preventive health program to Prevention Program www.cchealth.org/ser make health care available to of Contra Costa vices/child_health children who are uninsured or Health Services under-insured. Offers preventive 597 Center Ave. Ste. health assessments and referrals 280 for follow-up care. Martinez, CA 94553

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Other Agency CARE Phone/Web Site Services Provided Title I Name/Address Act Funds Children’s Hospital 510-428-3387 Social and health care services to Oakland Department 510-428-3388 adolescents 12-17. Information of Adolescent www.childrenshospital and referrals, case management, Medicine Teen Clinic oakland.org health maintenance, HIV testing, 747 52nd St. counseling for victims of sexual Oakland, CA 94609 abuse, crisis intervention, teen perinatal program, family planning services. STD screening. Teen AIDS Prevention Project provides teen support groups and peer counseling. Children’s Hospital 510-428-3010 HIV testing, evaluation, treatment Oakland Department www.childrenshospital and follow-up services for of Infectious Diseases oakland.org persons 18 and under. Biweekly Pediatric AIDS parent education and support √ √ Program groups. Youth Clinic. 747 52nd St. Oakland, CA 94609 City of Berkeley 510-644-8571 HIV testing and counseling with Public Health Clinic www.ci.berkeley.ca.us support services. 830 University Ave. /publichealth/publiche Berkeley, CA 94710 althclinic/phc.html City of Berkeley 510-644-6500 Eligibility screening for AIDS Drug Department of Public www.ci.berkeley.ca.us Assistance Program; Nurse-of- Health and Human /HHS/health the-Day telephone assistance; Services/Department home visits for persons with of Public Health HIV/AIDS. Prevention education 2344 6th St. through Health Promotion. Berkeley, Ca 94710 Coalition for 510-653-3808 General mental health services. Alternatives in Mental HIV testing. Health Berkeley Drop- In Center 3234 Adeline St. Berkeley, CA 94703

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Other Agency CARE Phone/Web Site Services Provided Title I Name/Address Act Funds Contra Costa County 925-313-6771 The agency is dedicated to Health Services AIDS http://www.cchealth.or fostering the development, Program g/groups/aids/ implementation, and coordination 597 Center Avenue, of programs to reduce the Suite 200 transmission of HIV, provide Martinez, CA 94553 comprehensive services for people with HIV, and enhance √ √ community awareness of AIDS. The agency coordinates and oversees expenditure and management of Title I funds in Contra Costa County Contra Costa Health 510-231-8669 Comprehensive program Services Teenage www.cchealth.org/ser designed to address the physical, Program (TAP) vices/teenage_progra social and emotional concerns of 100 38th Street m Contra Costa County youth. Richmond, CA 94804 Health education programs and and presentations on a variety of 597 Center Ave., Ste. health topics including HIV/AIDS. 365 Martinez, CA 94553 Diablo Valley AIDS (925) 686-3822 Provides food, nutritional Center (DVAC) http://www.dvac.org assistance and other support 4090 Nelson Avenue, services for individuals with Suite F HIV/AIDS and their families. Concord, CA 94520- Services include food bag √ √ 5328 distributions, nutrition counseling, education, information and referral, and other support services. East Bay Agency for 510-531-7551 Outpatient individual and family Children Pediatricare www.ebac.org counseling and support groups 2540 Charleston St. for children, teens and their Oakland, CA 94602 families impacted by life- √ threatening disease including HIV/AIDS. East Bay AIDS Center 510-204-1870 Comprehensive primary HIV (EBAC) at Alta Bates www.altabates.com/cli care, access to clinical trials, HIV Summit Medical nical/aids_scvs.html testing. Center √ 2850 Telegraph Ave., Ste. 110 Berkeley, CA 94705

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Other Agency CARE Phone/Web Site Services Provided Title I Name/Address Act Funds East Bay Center for 510-893-5683 Confidential supportive Attitudinal Healing discussion groups for persons 3278 West St. with life-threatening or chronic Oakland, CA 94608 illness. East Bay Community 510-548-4040 Primary legal service provider in Law Center www.ebclc.org the East Bay for people with HIV, 3130 Shattuck Ave. specializing in helping obtain Berkeley, CA 94705 disability benefits. HIV Outreach √ Project at four Oakland sites to provide legal assistance and information. East Bay Community 510-446-7120 Substance abuse and mental Recovery Project www.ebcrp.org health treatment, case Health Division management, alternative 2251 San Pablo Ave., treatments and medical care to √ √ Ste. 222 persons with HIV and HIV at-risk Oakland, CA 94612 populations. East Bay Perinatal 510-653-3335 Low to no-cost comprehensive Medical Associates www.ebpma.com perinatal services to pregnant 350 30th St., Ste. 205 teen and adult women, including Oakland, CA 94609 HIV testing and counseling. Eden I & R, Inc. AIDS 510-537-2600 Housing and social service Housing and 877-4-AIDS-INFO referrals for people with Information Project HIV/AIDS. Database of AIDS- 570 B Street dedicated housing. Housing Hayward, CA 94541 workshops for case managers and clients. Familias Unidas 510-412-5930 Counseling, advocacy and 205 39th St. 925-427-7935 information services primarily to Richmond, CA 94805 www.familias- the Latino community in Contra and unidas.org Costa County. HIV/AIDS services √ 2260 Gladstone Drive, include education and prevention, Ste. 1 therapy and case management Pittsburg, CA 94565 services. Family Health Toll- 800-696-9644 Information and referral to family Free Line health services including 597 Center Ave., Ste. AIDS/HIV counseling, treatment, 365 testing. Martinez, CA 94553

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Other Agency CARE Phone/Web Site Services Provided Title I Name/Address Act Funds Family Support 510-834-2443 Respite services including to HIV- Services of the Bay www.fssba-oak.org affected families and select Area Respite Care relative caregivers of children Program who are perinatally substance- √ 554 Grand Ave. exposed. Oakland, CA 94610 Food Bank of Contra 925-676-7543 Food distribution for more than Costa & Solano www.foodbankccs.org 70,000 hungry people each PO Box 271966 month. Concord, CA 94527 Fremont Mission: 510-438-0422 In-home support, transportation, AIDS Program www.fremontaids.com home food delivery, emotional PO Box 1733 support to persons with Fremont, CA 94538 HIV/AIDS, their friends, families and caregivers. Genard AIDS (925) 943-2437 Provides services, support, and Foundation http://www.Genard.or education to people with 1630 No. Main Street, g HIV/AIDS, their families and Suite 102 loved ones, as they move through Walnut Creek, the trauma of living with CA 94596 HIV/AIDS, thereby providing them with the capacity to face death with dignity and peace. Harm Reduction 510-444-6969 Drug-related education and Coalition www.harmreduction.o support to health professionals, 1440 Broadway #510 rg substance users and the Oakland, CA 94612 community. Health, Housing, and (510) 235-5969 Offers comprehensive services in Integrated Services www.cchealth.org/ser health care, mental health, Network (HHISN) vices/homeless/hhisn substance abuse treatment, 101 Broadway Avenue _enhancement_progr social and vocational services, Richmond, CA 94804 am.php peer counseling and employment opportunities in conjunction with service enriched housing for single adults who are homeless/formerly homeless or at risk and have HIV/AIDS, mental health issues and/or substance abuse disorders.

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Other Agency CARE Phone/Web Site Services Provided Title I Name/Address Act Funds HELPLINK 800-273-6222 Comprehensive and confidential 50 California St., #200 www.ncccsf.org health and human care San Francisco, CA information and referrals. 94111 Hemophilia Council of 510-568-7074 AIDS education and prevention. California Individual and group counseling, 7700 Edgewater Dr., support groups including Ste. 710 women’s and men’s groups. Oakland, CA 94621- 3017 Hemophilia 510-568-6243 Education, counseling, support Foundation of www.hfwconline.org groups, recreation activities, Northern California advocacy for persons with 7700 Edgewater Dr., hemophilia. Support group for Ste. 710 men with HIV, their partners Oakland, CA 94621- and/or relatives. 3017 HIV/AIDS Warmline 925-674-2190 Warmline with nurse educator 2450 East St. www.jmmdhs.com available to answer questions, Concord, CA 94520 provide information and make referrals. HIV Education and 510-437-8899 Volunteer-based community Prevention Project of outreach to prevent spread of HIV Alameda County and to promote safer injection PO Box 7522 methods. Street and community Oakland, CA 94601 outreach, prevention and harm reduction counseling. Herbal education and treatment. Casa Segura provides drop-in access to risk reduction supplies, referrals, HIV testing and counseling, case management, needle exchange, employment and legal assistance, food and clothing on a limited basis. Hope Hospice, Inc. 925-829-8770 Comprehensive end of life care 6500 Dublin Blvd., Ste. www.hopehospice.co for persons with terminal 100 m illnesses, and emotional support Dublin, CA 94568 for their families.

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Other Agency CARE Phone/Web Site Services Provided Title I Name/Address Act Funds Horizon Services, Inc. 510-653-5865 Full range of recovery, prevention PO Box 4217 www.horizonservices. and educational services to Hayward, CA 94544 org persons with alcohol or drug related problems and those affected by another’s alcohol or drug use. Multiple sites featuring residential recovery centers, some featuring HIV education and testing. Hospice and Palliative 925-609-1830 Home palliative care, in-patient Care of Contra Costa www.hospicecc.org hospice facility, grief counseling. 3470 Buskirk Ave. Pleasant Hill, CA 94523 Humanistic 510-875-2300 Methadone maintenance and Alternatives to detoxification program providing Addiction, Research outpatient services to heroin and Treatment users. HIV/AIDS education and 10850 MacArthur Blvd. testing. Oakland, CA 94605 In Memory Foundation 510-582-7189 Assists low-income families and 29110 Verdi Rd. friends of persons who have died Hayward, CA 94544 of AIDS with burial expenses. Independent Living 925-687-8844 Promotes full participation and Resource www.ilrccc.org inclusion of disabled persons in 3200 Clayton Road community life; provides Concord, CA 94520 advocacy and support. Kaiser Permanente 510-752-1000 General acute short-term Medical Center – oakland.kaiser.org inpatient care. HIV community Oakland education programs, HIV 280 W. MacArthur Blvd. specialty care and case Oakland, CA 94611 management, AIDS Drug Assistance Program, HIV testing. La Clinica de la Raza 510-535-4000 Comprehensive medical and Fruitvale Health www.laclinica.org dental care. Offers HIV/AIDS Project testing and case management 1515 Fruitvale Ave. with emphasis on providing initial √ √ Oakland, CA 94601 emotional support for clients. AIDS education programs. AIDS Drug Assistance Program.

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Other Agency CARE Phone/Web Site Services Provided Title I Name/Address Act Funds La Clinica de la Raza 925-431-1230 Comprehensive health services Pittsburg Medical www.laclinica.org including early intervention Clinic services, chronic disease 2240 Gladstone Ave., management, education, HIV Ste. 4 testing. Pittsburg, CA 94565 Larkin Street Youth 415-673-0911 Continuum of services to Services www.larkinstreetyouth homeless and runaway youth, 1044 Larkin St. .org including medical care, housing San Francisco, CA and psychosocial support for 94109 youth with HIV/AIDS, including a residential care program. Lifelong Medical Care 510-204-4835 Primary care, perinatal care, Berkeley Primary Care www.lifelongmedical.o pediatrics, gynecological PO Box 11247 rg services, HIV testing, Berkeley, CA 94712 acupuncture detoxification, and psychosocial services. HIV √ √ program also offers nutritional and mental health counseling, case management, and acupuncture. Martinez Health (800) 495-8885 Provides a variety of medical care Center http://cchealth.org services by physician specialists Immunodeficiency for HIV-positive individuals, as Disease Clinic well as on-site social work √ 2500 Alhambra Avenue services. Martinez, CA 94553 Namaste 510-547-7702 Emotional support and individual PO Box 3680 counseling by trained volunteers Berkeley, CA 94703 to persons dealing with a life- threatening illness. Narcotics Education 510-535-2303 Prevention and treatment League www.nel- services for alcohol and drug 3315 International Blvd. alamedacounty.org abuse in the Latino community. Oakland, CA 94601 HIV/AIDS education and HIV testing. National Native 510-444-2051 National clearinghouse for Native American AIDS www.nnaapc.org American-targeted AIDS/STD Prevention Center health education materials, 436 14th St., Ste. 1020 literature and speakers. Oakland, CA 94607

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Other Agency CARE Phone/Web Site Services Provided Title I Name/Address Act Funds New Connections 925-363-5000 Provides substance abuse 3024 Willow Pass www.newconnections. recovery services in Contra Costa Concord, CA 94519 org County for persons living with HIV/AIDS. Comprehensive support services for HIV-infected persons, their families, friends √ √ and caregivers. Provides adult day services for HIV-positive individuals and outreach for West Contra Costa County residents. Pacific Center for 510-548-2192 Community center and mental Human Growth www.pacificcenter.org health agency for lesbians, gay 2712 Telegraph Ave. men, bisexual and transgendered Berkeley, CA 94705 people. HIV/AIDS program √ provides crisis counseling, emotional support, peer groups, referrals and social opportunities. Pathways Hospice 510-755-7855 In-home medical and emotional 7901 Oakport St., Ste. www.hospicehomecar care for patients and families 3500 e.org during the final phases of terminal Oakland, CA 94521 illness. Pittsburg Pre-School 925-439-2061 Training, health and social and Community www.ppscc.info services to low and no-income Council families in Contra Costa County. 1760 Chester Dr. HIV services include HIV √ Pittsburg, CA 94565 prevention and education, case management, benefits assurance, community outreach. Planned Parenthood 415-441-7858 Planned Parenthood Affiliate Golden Gate www.ppgg.org Organization serving Bay Area Administrative Eastmont Center: counties including Alameda. Headquarters 510-613-8085 Multiple sites. Reproductive 815 Eddy St., Ste. 300 Hayward Center: health services including HIV San Francisco, CA 800-967-7526 information and HIV testing. 94109 MacArthur Center: 510-601-4705

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Other Agency CARE Phone/Web Site Services Provided Title I Name/Address Act Funds Planned Parenthood 925-676-0505 Planned Parenthood Affiliate Shasta-Diablo www.ppshastadiablo. Organization serving Northern Administrative Office org California counties including 2185 Pacheco St. Antioch: Contra Costa. Multiple sites. Concord, CA 94520 9250754-4550 Reproductive health services Concord: including HIV information and HIV 925-676-0300 testing. Richmond: 510-232-1250 Richmond/Hilltop: 510-222-5290 San Ramon: 925-838-2108 Walnut Creek: 925-935-3010 Positive Resource 415-777-0333 Benefits counseling, employment Center positiveresource.org services and provider training for 973 Market St., 6th Fl. persons who are HIV positive. San Francisco, CA 94103 Project Inform 415-558-8669 HIV/AIDS care, treatment and 205 13th St. Ste. 2001 www.projinf.org policy information and advocacy San Francisco, CA for persons with HIV/AIDS and 94103 their families, friends and care providers. Offers national HIV/AIDS treatment Hotline. Project Open Hand of 800-551-6325 Prepares and delivers meals and the East Bay www.openhand.org groceries to people with 4700 Telegraph Ave. symptomatic HIV or AIDS. Food √ Oakland, CA 94609 bank. Nutrition counseling available by appointment. Providence House 510-444-9839 Subsidized housing for physically 540 23rd St. www.providence.org/L disabled, low-income individuals, Oakland, CA 94612 ong_Term_Care/Hous with priority given to HIV/AIDS ing/e70phoak.htm diagnosed persons. Resources for 510-841-4410 Non-profit housing development Community www.rcdev.org corporation to provide housing for Development (RCD) low-income persons, and 2131 University Ave., includes housing for persons Ste. 224 disabled due to HIV/AIDS. Berkeley, CA 94704

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Other Agency CARE Phone/Web Site Services Provided Title I Name/Address Act Funds Richmond Health 510-231-1215 Title III-funded Early Intervention Center site. Provides a variety of medical 100 38th Street care services through HIV- √ Richmond, CA 94804 specialist physicians, as well as on-site social work services Rubicon Programs, 510-235-2025 Employment, housing, legal and Inc. www.rubiconprogram support services for homeless or 2500 Bissell Ave. s.org disabled persons. Case Richmond, CA 94804 management to assist with self- sufficiency and housing. Permanent supportive housing for √ individuals with a mental health disability or HIV/AIDS at three sites. HIV legal services provided through the Hawkins Center. San Francisco AIDS 415-487-3000 Comprehensive services and Foundation www.sfaf.org advocacy for persons with HIV. PO Box 426182 Case management, counseling, San Francisco, CA housing services, peer support 94142 groups, special services for women with HIV. Second Chance Inc. 510-792-4357 Counseling, crisis intervention, PO Box 643 www.secondchancein hotline, education, support Newark, CA 94560 c.com groups for problems such as drugs, alcohol, domestic violence, parenting, HIV/AIDS, etc. Offers AIDS workshops, HIV testing. Sexual Minority 510-834-9578 Provides support groups, Alliance of Alameda www.smaac.org counseling, health education, County (SMAAC) prevention case management, 1738 Telegraph Ave. peer advocacy for HIV positives, Oakland, CA 94612 drop-in center for LGBTQ youth. Shelter, Inc. HIV (925) 335-0698, ex. Assists clients with HIV/AIDS with Housing Advocacy 141 locating/maintaining affordable Program www.shelterincofccc.o housing. Housing Advocate 1815 Arnold Drive rg educates clients regarding Martinez, CA 94553 landlord/tenant responsibilities √ and can provide rental assistance to eligible clients. Receives HOPWA funding.

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Other Agency CARE Phone/Web Site Services Provided Title I Name/Address Act Funds Sisters of Providence 5110-444-0839 Subsidized housing to physically House www.sistersofprovide disabled, low income persons, 540 23rd St. nce.net with priority given to those with Oakland, CA 94612 AIDS. Summit Medical 510-869-6514 Comprehensive medical Center www.altabates.com/cli outpatient care including HIV Adult Immunology nical/aids_scvs.html testing and nutrition counseling. Clinic Support and counseling, access 3012 Summit St., 3rd Fl. to clinical trials. AIDS Drug Oakland, CA 94609 Assistance Program. Sutter VNA and 510-347-6870 Comprehensive home health care Hospice www.suttervnaandhos program and home hospice 1900 Powell St., Ste. pice.org program. 300 Emeryville, CA 94608 Terra Firma Diversion 510-675-9362 Drug and domestic violence Educational Services diversion groups for court 30030 Mission Blvd., mandated individuals and Ste. 112 education and group support Hayward, CA 94544 services for the general public. Offer AIDS education classes and drug testing services. Tiburcio Vasquez 510-471-5880 Primary care community clinic for Health Center www.tvhc.org children and adults. Provides free 33255 9th St. AIDS education and community Union City, CA 94587 information to schools, churches, and other organizations. HIV testing. Tri-City Health Center 510-770-8040 Community health center offering 39500 Liberty St. www.avenir1.com/tch comprehensive health services. Fremont, CA 94538 c/html AIDS/HIV services include primary care, case management, testing, counseling, support √ √ groups, financial assistance, and acupuncture. AIDS Drug Assistance Program. Ujima House East 510-569-8933 Provides social, health care and Oakland Family Life promotion, and educational Resource Center services. HIV/STD testing and 9925 International referrals. Blvd., #9 Oakland, CA 94603

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Other Agency CARE Phone/Web Site Services Provided Title I Name/Address Act Funds Valley Community 925-462-5544 Comprehensive health and social Health Center services. Valley AIDS Project 4361 Railroad Ave., offers HIV/AIDS support services Ste. A including case management and Pleasanton, CA 94566 support groups for friends, family and caregivers. West Oakland Health 510-835-9610 Comprehensive medical services. Council, Inc. West Education and prevention Oakland Health Center programs and counseling 700 Adeline St. including for HIV/AIDS. HIV Oakland, CA 94607 testing. Women’s Daytime 510-548-2884 Daytime drop-in center for Drop-in Center homeless or at risk single women 2218 Acton St. and women and children. HIV Berkeley, CA 94702 prevention group. W.O.R.L.D. (Women 510-986-0340 An information and support Organized to Respond www.womenhiv.org network by, for and about women to Life-Threatening with HIV/AIDS. Publishes Diseases) quarterly newsletter, conducts 414 13th St., 2nd Floor AIDS treatment education school, Oakland, CA 94612 retreats for women with HIV, √ peer outreach to HIV-positive men and women, perinatal peer advocacy, AIDS resource library, information and referrals.

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H. Barriers to Care

The challenge of providing effective, equitable HIV care is especially daunting within the Oakland EMA because our region includes so many pockets in which extreme poverty, homelessness, underachieving schools, soaring crime rates, and disconnection from traditional health and support services are common. The local HIV epidemic has thus far had its greatest impact on communities of color, especially African American and Hispanic/Latino communities; on the economically disadvantaged, including the homeless and low-income persons; on sexual minorities such as men who have sex with men, bisexual men, and transgender persons, including youth and adults; and on injection and other drug abusers. These underprivileged, underserved, and under- recognized populations face overwhelming barriers to accessing and maintaining care, and once identified are more costly to care for. In a climate of steadily diminishing HIV resources and continually growing HIV-infected populations, these issues pose serious and continuing barriers to the formation of a truly comprehensive and equitable system of care that is capable of meeting the needs of all disadvantaged and impoverished HIV-infected individuals in our region.

The epidemic of injection drug use in the Oakland EMA, for example, is estimated at a shocking rate of almost 1,500 injection drug users per 100,000 population - a crisis that continually fuels the epidemics of HIV and Hepatitis C in our region. Highly addictive crack cocaine and methamphetamine fans the flames as well by increasing risky sexual behaviors. Polydrug use is also widespread, with alcohol, marijuana, crack, heroin, and methamphetamine being used in varying combinations by the majority of substance users. One study of African American women accessing state-funded HIV testing sites in California found that crack adds significantly to the risk of HIV infection by African American women in particular. The link between sex work and crack cocaine has also been shown to increase HIV infection rates in both male and female prostitutes through exchange of sex for money or drugs, and through casual sex among the population. Service providers report that they are seeing more injection drug users entering treatment with full blown AIDS as a result of a denial of their illness. Once in care, many substance users are not compliant with medical advice, suggesting the need for comprehensive and fully linked drug treatment and HIV care and support services. Men who have sex with men and also inject drugs face dual risks, as demonstrated by the SF Men’s Health Study in which injection drug-using gay and bisexual men had a greater than 40% increased risk of HIV infection as compared to non-gay and bisexual men.25

Within the Oakland EMA, crime is also very much associated with drug use. According to statistics from the California Alcohol and Drug Division, Alameda and Contra Costa Counties together had a rate of 48.9 crimes per 1000 population in 2001, above California’s average rate of 30.8.26 Adult arrests for drug violations placed Alameda County 46th out of 58 counties and Contra Costa 30th. Oakland, with a high crime rate, receives a high proportion of parolees. As of January 31, 2005 the total number of parolees in release to Region 2 Alameda County parole unit cities was 5,251.

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The prevalence of diseases among inmate populations (and recently released) is considerably higher than the general population: TB four times; HCV 9-10 times; AIDS 5 times; HIV infection 8-9 times; schizophrenia or other psychotic disorder 3-5 times and substance abuse- 83% exhibiting addiction at time of incarceration. 27

In order to explore the way in which these and other barriers may limit the proportion of HIV-infected individuals who enter and remain in care in our region, what was then called the Oakland EMA HIV Health Services Planning Council in 2001 embarked upon its study of out-of-care populations by commissioning an assessment of Service Needs of Out of Care People with HIV/AIDS. Prepared by the Center for Applied Local Research, and based on the findings of a series of 11 focus groups held with out of care populations throughout the Oakland EMA as well as key informant interviews, the report documents the key service needs of people not currently in care. In 2002, HIV service providers and planners presented the Alameda/Contra Costa Country Out of Care Summit – a unique gathering designed to gain new insights into the reasons why many people with HIV are not in care, and what can be done to bring them into care. Significant findings of the report include identification of a series of key barriers to care that exist for out of care populations, both in terms of barriers people living with HIV/AIDS bring with them themselves, and barriers that the healthcare system creates. These include the following:

Difficulty in Relating to the Healthcare System; Psychological and Emotional Barriers; Lack of Knowledge; Unstable Living Conditions; Substance Abuse; Difficulty in Understanding the Health Care System; Difficulty in Entering the System; Difficulty in Accessing Providers; System Seen as Inhospitable and Unwelcoming; and Race and Language Barriers

The Oakland EMA contains diverse populations that are caught in severe situations. The complexity of HIV/AIDS care is compounded by the variety of issues facing each infected person. In the present climate of limited funding, it becomes even more imperative to build a system of care that delivers comprehensive services to the complex, multi-need client in a compassionate and respectful manner. The Oakland EMA is on the cutting edge of nation-wide HIV/AIDS community planning processes. Having merged its Title I/II Care and Treatment Planning Council with the countywide HIV Prevention Planning Council, the new Collaborative Community Planning Council is charting a course through the full spectrum of HIV/AIDS prevention, education, testing, outreach, social services and core medical programs for a community with abundant diversity and difficulties.

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SECTION II: WHERE DO WE WANT TO GO? WHAT SYSTEM OF CARE DO WE WANT?

A. Shared Vision for System Changes

During its April 2005 Planning Retreat, the newly merged Oakland EMA Collaborative Community Planning Council formulated a new set of Mission, Vision, and Values Statements to assert its commitment to a more fully integrated system of HIV prevention and care within the context of a growing and increasingly diverse and underserved HIV-infected population. The following summarize the EMA’s overall approach to prevention and care in light of a continually changing epidemic and a shifting organizational and resource context.

Mission Statement: The Collaborative Community Planning Council acts as a catalyst to provide a continuum of high quality services for all people living with and affected by HIV/AIDS by empowering our communities, providing responsible stewardship and planning, and advocating on our community’s behalf.

Vision Statement: We boldly dare to stop all new HIV infections while improving the quality of life for those living with HIV disease. The Collaborative Community Planning Council will provide services that are linguistically and culturally appropriate and that:

Outreach to the underserved; Educate all communities; and Reduce HIV stigma.

Values Statement: We will employ a comprehensive and inclusive process, which is both data and community-input driven. Our goal is to develop an integrated model to prevent the spread of HIV while providing accessible and high quality care for infected and affected members of the community.

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SECTION III: HOW WILL WE GET THERE? HOW WILL OUR SYSTEM NEED TO CHANGE TO ASSURE AVAILABILITY AND ACCESSIBILTY TO CORE SERVICES?

A. Introduction

The system of goals, objectives, and action steps described below was developed through an incremental process spearheaded by the Oakland EMA Comprehensive Plan Working Group. Meeting over a period of months beginning in early 2005, the ad hoc Working Group began by reviewing progress made toward the goals and objectives contained in our 2002 Comprehensive Plan. These findings were then used to adapt and modify the overarching goals contained in the previous Plan, and to develop a set of time-phased objectives designed to capture and encompass the specific Action Steps for the Plan period of March 1, 2006 through February 28, 2009. Goals, objectives, and action steps developed by the Working Group were reviewed, revised, and approved by the Oakland EMA HIV Services Planning Committee as a whole.

The Working Group faced a dilemma in deciding how to frame the long and short- term objectives contained in this year’s Comprehensive Plan. Because the Working Group had identified a relatively large number of activities and action steps for the coming three years, the group felt that it might be too cumbersome to list all activities as separate objectives, and opted instead to develop a series of relatively broad, overarching objectives which could encompass more specific action steps, each of which would also be time-phased. For this reason, the action plan below consists of a series of goals, objectives, and measurable action steps, with each set of action steps corresponding to the specific objective under which it is listed.

Many of the three-year action steps below will result in broad-based examinations of the existing system of care in the Oakland EMA and the way in which the Oakland EMA Collaborative Community Planning Council does business. During 2006, this includes a year-long, facilitated strategic planning process involving several full-day meetings to be attended by Council members, consumers, and providers. The goal of the process will be to systematically explore all aspects of both the local HIV care system and the process through which CARE Act funds are prioritized, allocated, and managed in the Oakland EMA, and to make the difficult decisions that are needed to bring about significant enhancements in this system. The strategic planning process is expected to coincide with the process for addressing changes that may come about through the upcoming Ryan White CARE Act reauthorization. The action plan also outlines several key steps designed to increase coordination among the EMA’s two counties; to strengthen training and certification for HIV service providers; and to explore movement toward a continuous needs assessment process for the Oakland EMA. The goals,

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objectives, and action steps below outline what we believe is an exciting future for HIV care and service delivery in our region - one that gives us our best chance to cope with potential resource reductions while designing an ever-more effective, inclusive, and efficient spectrum of care.

B. Long-Term Systemic Goals and Objectives

Goal # 1: To ensure access to a comprehensive coordinated EMA-wide continuum of HIV care that incorporates HIV prevention activities.

Objective # 1.1.: Between March 1, 2006 and February 28, 2009, to provide an integrated, comprehensive continuum of HIV services for low-income and underserved populations, with a focus on HRSA core services.

Action Step # 1.1.1.: Beginning on March 1st of each year, begin to collect essential background data related to the prioritization and allocation process, including planning and sponsoring community-based Town Hall meetings, gathering epidemiological and service utilization data, and conducting a bi-annual needs assessment.

Action Step # 1.1.2.: Beginning on or around May 1st of each year, begin conducting a facilitated, two-part prioritization and allocation process designed to utilize Title I resources to support the most effective continuum of care.

Action Step # 1.1.3.: During each year’s prioritization and allocation process, re- examine and reaffirm the Council’s definition of essential services, incorporating HRSA-defined core services.

Action Step # 1.1.4.: By August 31st of each year, complete the prioritization and allocation process supporting an integrated continuum of care that provides essential services for populations in greatest need.

Action Step # 1.1.5.: By August 31st of each year, complete a detailed contingency plan for dealing with potential reductions or expansions in Title I funding during the future CARE Act fiscal year.

Action Step # 1.1.6.: Between March 1, 2006 and February 28, 2008, continue to explore the possibility of preparing two-year Title I service contracts for selected service categories within the Oakland EMA.

Objective # 1.2.: Between March 1, 2006 and February 28, 2009, to utilize and enhance case management services to coordinate client care, ensure care access, and ensure client empowerment and self-management.

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Action Step # 1.2.1.: By August 31st of each year, incorporate annual decisions regarding case management funding and structure into the annual prioritization and allocation process.

Action Step # 1.2.2.: Between March 1, 2006 and August 31, 2007, under the leadership of the Alameda and Contra Costa County AIDS programs, develop and implement a detailed set of case management practices and procedures consistent across the EMA’s two counties in order to ensure comprehensive care access and effective client empowerment throughout the Oakland EMA.

Action Step # 1.2.3.: Between September 1, 2007 and August 31, 2008, develop and implement a client-centered case management certification program for both new and existing case management providers throughout the Oakland EMA, including implementation of case management certification standards and procedures.

Action Step # 1.2.4.: Between March 1, 2007 and August 31, 2007, explore case management best practices related to increasing client empowerment and self- management and reducing dependency on case management and other system services.

Action Step # 1.2.5.: Between September 1, 2007 and February 28, 2009, continue to monitor, evaluate, and update the countywide case management certification and practice model in order to increase its effectiveness and sensitivity to clients’ needs.

Action Step # 1.2.6.: Between September 1, 2007 and February 28, 2009, develop and implement one or more new strategies for continually assessing clients’ need for case management and empowering clients to become more self-reliant in regard to HIV care access.

Objective # 1.3.: Between March 1, 2006 and February 28, 2009, to ensure that the local system of care continually promotes long-term retention in care and adherence to HAART medications for those who wish to take them.

Action Step # 1.3.1.: By February 28, 2009, develop common standards related to mental health and substance abuse among the Title I, Title III, and Title IV service systems of the Oakland EMA, in response to an EMA-wide need identified through the Continuous Quality Improvement system.

Action Step # 1.3.2.: By February 28, 2009, continue to refine the work of the combined prevention and care Planning Council in order to increase coordination and integration of prevention and care planning and allocation activities by the

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Council, including expanding prevention programs for HIV-positive and high-risk negative persons.

Objective # 1.4.: Between March 1, 2006 and February 28, 2009, to ensure coordination and integration of Title I-funded services with all other service and resource programs available to persons with HIV, in order to maximize Title I funds and to ensure that these funds are used as the funding source of last resort, including ensuring that people with HIV have access to all benefits and support programs for which they are eligible.

Action Step # 1.4.1.: Between March 1, 2006 and February 28, 2009, continually strengthen systems through which contactors are required to ensure maximum billing of all potential non-Title I resources, including through enhanced agency monitoring and expanded benefits training.

Action Step # 1.4.2.: Between March 1, 2006 and February 28, 2009, examine activities to support the provision of adequate benefits and legal assistance to ensure that HIV-positive individuals and agencies are informed of and able to obtain and renew benefits for which they are eligible, including providing information and support related to new Medicare Part D requirements and options.

Action Step # 1.4.3.: Between March 1, 2006 and February 28, 2009, continue to expand and enhance coordination and collaboration with both HIV-specific and non- HIV-specific agencies delivering HIV service and support who are not funded through local Title I resources.

Objective # 1.5: Between March 1, 2006 and February 28, 2009, to continue to utilize community-centered planning to prioritize services and allocate resources in order to ensure appropriate, sensitive, and cost-effective resource utilization.

Action Step # 1.5.1.: By January 31, 2006, convene a new Strategic Planning Task Force to develop and oversee a year-long reassessment and reorganization process to restructure the annual prioritization and allocation process of the Oakland EMA Collaborative Community Planning Council; to revisit goals, objectives, and action steps contained within the current Three-Year Plan; and to potentially reshape the overall system of Title I-funded service provision and allocation in the EMA in response to changes in the epidemic and in relation to potential changes included in 2006 Ryan White CARE Act reauthorization, such as by moving to a system of multi- year allocations and contracting.

Action Step # 1.5.2.: By February 28, 2006, complete a detailed timeline for the strategic planning process, and identify and secure one or more appropriate outside facilitators for this process.

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Action Step # 1.5.3.: Upon receipt of the FY 2006-2007 Title I allocation – and no later than February 28, 2006 – allocate adequate and appropriate funds to support the facilitation and management of the proposed strategic planning process.

Action Step # 1.5.4.: Between March 1 and December 31, 2006, sponsor an initial two-day planning retreat and a series of between two and four full-day meetings of the entire Planning Council – including representatives of the Alameda and Contra Costa County AIDS Offices and consumers – in order to re-examine specific aspects of Planning Council operation and organization, to increase cooperative interaction among Council members, and to develop new models of HIV service delivery, planning, allocation, and outcomes-based monitoring on an EMA- wide basis, incorporating interim findings from this process in the 2006 prioritization and allocation process.

Action Step # 1.5.5.: By March 31, 2007, develop, revise, and approve a new Three-Year Strategic Plan document outlining detailed outcomes and specific timeframes for accomplishing goals identified during the planning process.

Action Step # 1.5.6.: By August 31, 2006, include an allocation for a new comprehensive client needs assessment to be conducted in the Oakland EMA in 2007 using fiscal year 2007-2008 Title I funds.

Action Step # 1.5.7.: Between approximately January 1 and July 31, 2007, conduct, summarize, and report to the Planning Council on the comprehensive needs assessment, including information on consumer needs and demographics, gaps and barriers to care, overall satisfaction with services, and the cultural competency of services received.

Action Step # 1.5.8.: Between March 1, 2006 and February 28, 2009, conduct at least annual Town Hall meetings to gather client and consumer input regarding allocation and prioritization of funds, while providing ongoing opportunities for consumer participation in Council activities through membership and public comment.

Objective # 1.6: Between March 1, 2006 and February 28, 2009, to ensure coordination, collaboration, and service integration between and among the two counties that make up the Oakland EMA.

Action Step # 1.6.1.: By March 31, 2006, develop and complete implementation of common countywide outcome measures for all HRSA core services throughout the Oakland EMA.

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Action Step # 1.6.2.: Between April 1, 2006 and February 28, 2007, incorporate these outcome measures into EMA-wide standards of core service provision.

Action Step # 1.6.3.: Between April 1, 2006 and February 28, 2007, incorporate monitoring and reporting requirements related to the new outcome measures within the contracts of all Title I service providers, and use the resulting information to develop new, refined outcome measures incorporating baseline data for the 2007- 2008 fiscal year.

Action Step # 1.6.4.: Between March 1, 2007 and February 28, 2009, continue to collect outcome data, conduct provider training and orientation as needed, and refine outcome measures based on data received.

Action Step # 1.6.5.: Between March 1, 2006 and February 28, 2009, develop and implement a detailed set of practices and procedures for the four remaining HRSA core services funded in the Oakland EMA, including primary care, mental health, substance abuse, and oral health services.

Action Step # 1.6.6.: Between March 1 and August 31, 2009, develop and implement orientation and training programs for providers related to each new set of practices and procedures for the four core categories.

Action Step # 1.6.7.: Between September 1, 2007 and February 28, 2009, continue to monitor, evaluate, and update the new core services practice models and certification programs in order to increase their effectiveness and client sensitivity, and to track beneficial health outcomes and increases in client satisfaction.

Objective # 1.7.: Between March 1, 2006 and February 28, 2009, to ensure incorporation of prevention with positives programs, services, and training throughout the HIV service continuum, and ensure collaborative planning and integration between HIV service and HIV prevention programs in the EMA.

Action Step # 1.7.1.: Between March 1, 2006 and February 28, 2007, develop a EMA-wide system requiring contractors to assess prevention with positives needs related to each client on a regular basis, such as the need for prevention with positives support for active substance users, sero-discordant couples, and sero- diverse families.

Action Step # 1.7.2.: Between March 1, 2006 and February 28, 2008, expand the existing Contra Costa County risk-reduction training program into Alameda County, and require at least an annual prevention with positives training program for all relevant Title I-funded providers throughout the EMA.

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Action Step # 1.7.3.: Between March 1, 2006 and February 28, 2009, continue to require that contactors report on prevention with positives activities and initiatives that are incorporated into the full range of Title I CARE services, and establish protocols for addressing contractors who are non-compliant.

Goal # 2: To ensure parity of HIV service access throughout the Oakland EMA through culturally competent services that strive to reach all HIV- infected people in our region.

Objective # 2.1.: Between March 1, 2006 and February 28, 2009, to continually improve HIV service systems in order to better serve impoverished, hard-to-reach, out of care, and severe need populations, including multiply diagnosed populations, persons of color, women, active substance users, transgender persons, LGBTQ youth and people of color, homeless youth and adults, unattached youth, and incarcerated populations.

Action Step # 2.1.1.: Between March 1, 2006 and February 28, 2009, continually incorporate planning for serving severe need, hard-to-reach, and out-of-care populations into Planning Council decision-making, taking into consideration potentially reduced funding and potential changes to the Ryan White planning and allocation system.

Action Step # 2.1.2.: During the year-long strategic planning process conducted during the 2006-2007 year (see Objective # 1.5. above), incorporate new models and approaches to reaching, serving, and retaining in care severe need and hard-to- reach populations.

Action Step # 2.1.3.: Between March 1, 2006 and February 28, 2009, continue to collect and utilize data related to severe need, hard-to-reach, and special populations for consideration during the prioritization and allocation process.

Objective # 2.2.: Between March 1, 2006 and February 28, 2009, to ensure that the region’s entire HIV continuum incorporates culturally competent care at all levels of service and support.

Action Step # 2.2.1.: Between March 1, 2006 and February 28, 2009, expand the cultural competency skills needed for agencies to serve severe need populations, including not only cross-cultural and linguistic capacity, but the ability to serve diverse cultural communities such as active substance users, young gay men of color, transgender people, women, and the homeless, through at least annual cultural competency training programs.

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Action Step # 2.2.2.: Between March 1, 2006 and February 28, 2009, provide service utilization data on the proportion of ethnic and cultural minorities being served within the Oakland EMA system of care as part of the annual prioritization and allocation process, including a focus on youth and the transgender community.

Action Step # 2.2.3.: Between approximately January 1 and August 31, 2007, incorporate client feedback on the cultural competence and sensitivity of HIV services received as part of the 2007 comprehensive needs assessment process.

Action Step # 2.2.4.: Between March 1, 2006 and February 28, 2009, conduct at least annual Town Hall Meetings to solicit client input regarding the cultural competence and accessibility of HIV services.

Action Step # 2.2.5.: Between March 1, 2006 and February 28, 2009, continually assess the need for cultural competency training and orientation within both the Planning Council as a whole and its committees, and schedule and conduct at least one annual cultural competency training to meet this need.

Objective # 2.3.: Between March 1, 2006 and February 28, 2009, to ensure full coordination and integration with all HIV testing programs in the Oakland EMA so that HIV-diagnosed individuals have immediate access to the regional care continuum.

Action Step # 2.3.1.: By February 28, 2009, expand requirements within relevant Title I-funded service contracts in order to increase co-located outreach, testing, and care services, and to ensure immediate linkage of newly-diagnosed HIV- positive individuals to systems of HIV care.

Action Step # 2.3.2.: Between March 1, 2006 and February 28, 2008, incorporate language in all relevant Title I contracts requiring linkages to established HIV testing programs, and encouraging collaborative programs that link clients to care immediately upon their receiving an HIV diagnosis.

Action Step # 2.3.3.: Between March 1, 2006 and February 28, 2009, continue to utilize Minority AIDS Initiative funding to ensure linkage between jail and prison- based outreach programs and the HIV care system in order to ensure that incarcerated individuals have access to HIV care and treatment and HIV prevention programs immediately upon their release.

Action Step # 2.3.4.: Between March 1, 2006 and February 28, 2009, participate in the development of collaborative programs that seek to provide ongoing HIV prevention education and support to high-risk HIV-negative individuals who participate in HIV testing within the Oakland EMA.

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Objective # 2.4.: Between March 1, 2006 and February 28, 2009, to continually solicit and incorporate consumer input and feedback in all service planning and enhancement activities, and include consumers at all levels of local and regional HIV service planning.

Action Step # 2.4.1.: Between March 1, 2006 and February 28, 2009, continue to ensure at least 33% representation by unaffiliated HIV-positive consumers on the Oakland Collaborative Community Planning Council, and work toward the goal of at least 50% representation by persons living with HIV/AIDS on the Planning Council as a whole, including affiliated and unaffiliated consumers.

Action Step # 2.4.2.: Between March 1, 2006 and February 28, 2009, continue to pro-actively solicit client and consumer input into process on a broad range of levels, including through broad-based consumer participation in the 2006 strategic planning process and the 2007 the comprehensive needs assessment; through at least annual Town Hall meetings; through consumer participation on the Planning Council and its committees; and through the collection of data related to client access and utilization of services.

Action Step # 2.4.3.: Between March 1, 2006 and February 28, 2009, continue to actively recruit and train new HIV-positive individuals to serve on the Oakland EMA Planning Council, providing adequate and appropriate training and support to empower them to effectively fulfill HRSA-mandated responsibilities.

Goal # 3: To ensure that persons with HIV have access to a high-quality, evidence-based system of care that measures health outcomes and incorporates continual assessment and planning.

Objective # 3.1.: Between March 1, 2006 and February 28, 2009, to ensure the continued implementation of a region-wide quality management program and quality management plan that provides outcome-based approaches to ensuring the quality of HIV care.

Action Step # 3.1.1.: Between March 1, 2006 and February 28, 2007, as noted in Objective # 1.6. above, develop and complete implementation of common countywide outcome measures for all HRSA core services throughout the Oakland EMA, and incorporate these outcome measures into EMA-wide standards of core service provision.

Action Step # 3.1.2.: Between April 1, 2006 and February 28, 2007, incorporate monitoring and reporting requirements related to the new outcome measures within the contracts of all Title I service providers, and use the resulting information to develop new, refined outcome measures incorporating baseline data for the 2007- 2008 fiscal year.

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Action Step # 3.1.3.: Between March 1, 2006 and February 28, 2009, monitor contractor progress toward specified outcome measures through data reports and technical assistance, modifying and refining outcomes on an ongoing basis as baseline data is obtained, while partnering with contracted agencies to help them track and achieve required program outcomes,

Action Step # 3.1.4.: Between March 1, 2007 and February 28, 2009, continue to work toward implementation of common outcome measures for all Title I-funded services throughout the Oakland EMA.

Action Step # 3.1.5.: Between March 1, 2006 and February 28, 2007, develop and pilot a new client satisfaction survey for Alameda County, building upon the existing client satisfaction survey already conducted in Contra Costa County.

Action Step # 3.1.6.: Between March 1, 2006 and February 28, 2007, in collaboration with the AIDS Education and Training Center, develop and present a new training program designed to orient and educate Planning Council members and consumers to the EMA’s emerging quality assurance and chronic care models.

Action Step # 3.1.7.: Between March 1, 2006 and February 28, 2009, conduct an annual evaluation of the quality management plan involving the Grantee, Planning Council members, contractors, and providers, and prepare and circulate an annual quality management plan update.

Action Step # 3.1.8.: Between March 1, 2006 and February 28, 2009, continue to assess and revise program monitoring tools, review standardized reporting mechanisms for program monitoring, and provide outcome data to the Planning Council to assist in priority setting and allocation.

Objective # 3.2.: Between March 1, 2006 and February 28, 2009, to continue to develop, review, and disseminate service standards related to Title I-funded service categories and programs.

Action Step # 3.2.1.: Between March 1, 2006 and February 28, 2009, develop new approaches to merging quality management activities with existing Title I service standards in order to ensure that Title I funds are only used to support effective and high-quality services.

Action Step # 3.2.2.: Between March 1, 2006 and February 28, 2009, as noted in Objective # 1.6. above, implement a common set of best practices and procedures to guide the provision of all Title I-funded services throughout the Oakland EMA.

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Objective # 3.3.: Between March 1, 2006 and February 28, 2009, to conduct EMA-wide needs assessments that assess service gaps among persons living with HIV and track emerging service demands and issues affecting HIV service organizations in order to reduce and eliminate service disparities within the EMA.

Action Step # 3.3.1.: As noted in Objective # 1.5. above, between approximately January 1 and August 30, 2007, conduct, summarize, and report to the Planning Council the findings of a new comprehensive client needs assessment, including information on consumer needs and demographics, gaps and barriers to care, overall satisfaction with services, and the cultural competency of services received.

Action Step # 3.3.2.: Between March 1, 2006 and February 28, 2009 – including as part of the proposed 2006 strategic planning process – explore the development and implementation of a continuous client needs assessment process in which client- level information is collected and summarized by the Planning Council on an ongoing basis – including through continual client satisfaction surveys, focus groups, and continuous quality improvement (CQI) activities - without the need for separate comprehensive assessments every two or three years.

Action Step # 3.3.3.: Between March 1, 2006 and February 28, 2009, expand the availability of client-centered data gathered by other local Ryan White-funded programs in our area as part of the annual prioritization and allocation process, including analyses of gaps and barriers to care and the nature and need of out of care populations.

Objective # 3.4.: Between March 1, 2006 and February 28, 2009, to collect comprehensive information on HIV epidemiology, local service patterns, and emerging socioeconomic factors in order to fully inform local prioritization and allocation activities, including information on youth and transgendered persons.

Action Step # 3.4.1.: Between March 1, 2006 and February 28, 2009, continue to provide comprehensive information to the Oakland EMA Collaborative Community Planning Council to guide the prioritization and allocation process, including epidemiological data and trends, client utilization and demographic reports, unmet needs estimates, and needs assessment data on hard-to-reach populations such as youth and transgendered persons.

Action Step # 3.4.2.: Between March 1, 2006 and February 28, 2009, expand the availability of data which describes the full range of funding available to support specific Title I services in the Oakland EMA, including and information on both Ryan White and non-Ryan White funding streams and – where possible - on the specific characteristics and numbers of clients served by each funded program.

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Objective # 3.5.: Between March 1, 2006 and February 28, 2009, to provide effective orientation and training of both HIV service staff and Oakland EMA Planning Council members to ensure high-quality care and effective local planning.

Action Step # 3.5.1.: Between March 1, 2006 and February 28, 2007, as part of the 2006 strategic planning process, conduct an assessment and a re-establishment of minimum standards for initial and ongoing training, education, and support of Oakland EMA Planning Council members.

Action Step # 3.5.2.: Between March 1, 2006 and February 28, 2009, work to ensure that there is an established EMA-wide training and education plan for all staff providing services within the CARE Act-funded Title I system, including standardized training, orientation, and certification processes for each HRSA core category.

C. Short-Term Title I Service Goals and Objectives

Goal # 4: To support a comprehensive, coordinated continuum of HIV care throughout the Oakland EMA.

Objective # 4.1.: Between March 1, 2006 and February 28, 2007, to utilize Ryan White CARE Act and all available complementary funds in order to support an integrated, comprehensive continuum of Title I-funded HIV services for low-income and underserved populations, with a focus on HRSA core services.

Action Step # 4.1.1.: Between March 1, 2006 and February 28, 2007, provide an estimated total of 16,628 units of ambulatory / outpatient HIV medical care to approximately 776 unduplicated, low-income HIV-infected individuals in the Oakland EMA.

Action Step # 4.1.2.: Between March 1, 2006 and February 28, 2007, provide an estimated total of 93,524 units of client-centered case management services to approximately 1,194 unduplicated, low-income HIV-infected individuals within the Oakland EMA.

Action Step # 4.1.3.: Between March 1, 2006 and February 28, 2007, provide an estimated total of 21,533 units of substance abuse services to approximately 323 unduplicated, low-income HIV-infected individuals within the Oakland EMA.

Action Step # 4.1.4.: Between March 1, 2006 and February 28, 2007, provide an estimated total of 19,624 units of mental health services to approximately 396 unduplicated, low-income HIV-infected individuals within the Oakland EMA.

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Action Step # 4.1.5.: Between March 1, 2006 and February 28, 2007, support an additional range of essential HIV care and support services needed to extend the quality and impact of the HIV care continuum in the Oakland EMA.

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SECTION IV: HOW WILL WE MONITOR OUR PROGRESS? HOW WILL WE EVALUATE OUR PROGRESS IN MEETING OUR SHORT AND LONG-TERM GOALS?

Implementation, Monitoring, and Evaluation Plan

Implementation, monitoring, and evaluation of the 2006-2009 Comprehensive HIV Services Plan will be the ongoing, shared responsibility of the Alameda County Office of AIDS and the Oakland EMA Collaborative Community Planning Council. The Planning Council’s Executive Committee will have day-to-day responsibility for monitoring progress toward Plan objectives and action steps, using a systematized action step grid to be collaboratively developed by the Grantee and the Executive Committee at the beginning of the 2006 calendar year. This grid will include action steps to be taken prior to the beginning of the 2006-2007 CARE Act funding year, and will feature clear incremental deadlines and identify entities responsible for achievement of specific action steps. The Executive Committee will discuss the Plan’s objectives and action steps as a regular monthly agenda item, and will provide a report on progress toward Plan-related objectives and action steps as part of its regular monthly reports to the Planning Council. The Executive Committee will also discuss key decisions or barriers related to attainment of Plan objectives and action steps, and will propose changes or modifications to the action plan to the Grantee and the Planning Council to address new and emerging issues or to address barriers in the attainment of specific outcomes. The Executive Committee is the ideal vehicle through which to monitor the Comprehensive Plan, since it includes representatives of the EMA’s two County AIDS offices as well as the chairs of all Council Committees, which in turn will allow for direct communication to and from committee members on Plan-related issues.

The action step grid to be collaboratively developed in early 2006 is expected to include some activities that will be the primary responsibility of the Alameda County Office of AIDS and/or its partner organization - the Contra Costa County Health Department AIDS Program. Both offices will discuss these Plan activities with the Executive Committee at the beginning of 2006, and will determine mutually agreed- upon deadlines for Plan-related activities and products. Both County agencies will report on their progress in completing Plan-related activities following a set of timelines and milestones developed in collaboration with the Executive Committee, and will propose modifications to the action plan on an as-needed basis.

The action step grid will also include tasks that are the specific responsibility of the Planning Council as a whole and/or of individual Council Committees, such as the Services Planning Committee, which coordinates the development and formation of regional HIV services, and the Program Management Committee, which has

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responsibility for the annual evaluation of the administrative mechanism. As with the two County AIDS programs, these committees will also regularly report to the Executive Committee on progress made toward Plan outcomes and action steps, and will revisit, revise, and amend specific Plan activities as needed to respond to change or address implementation barriers. Major changes to the Plan will be discussed and/or ratified by the Planning Council as a whole.

The Executive Committee and the Alameda County Office of AIDS will also jointly present a brief annual report to the Planning Council at the conclusion of each CARE Act fiscal year describing progress made toward objectives and action steps contained in the Plan, along with a proposed timeline for the following fiscal year. Specific barriers and issues that may have hampered the achievement of some action steps will be discussed by the Council in the course of this report, with timelines and/or activities modified as needed to keep Plan implementation on track.

The process of monitoring and evaluating the 2006-2009 Comprehensive HIV Plan will be fully coordinated with the Quality Management Plan currently being implemented within the Oakland EMA. In 2003, the Oakland EMA established its Quality Assurance Program in accordance with Human Resource and Service Administration’s (HRSA) Division of HIV Services mandate to place greater emphasis on evaluation activities as a core component of Federal grants. The Quality Management Program is a unique and ambitious compilation of quality assurance activities, the primary focus of which is to improve on quality management activities currently in place and to implement new strategies from best practices in order to improve health outcomes for individuals in the EMA. The purpose of the Oakland EMA Quality Management Program is to:

Assist Ryan White funded medical service providers in assuring that services adhere to HIV clinical practice standards and Public Health Service (PHS) guidelines;

Improve the quality of care/services and increase the probability of desired patient outcomes; Promote principles of continuous improvement in quality through

Assessment of current database or improving on a database to collect outcomes; Providing continuing education and training to providers, consumers and grantee staff; Soliciting input on improvement from consumers and providers; Conducting small test of change-Plan, Do, Study, Act (PDSA Cycle); and Using the Chronic Care Model as a guide for quality improvement or building on existing models; and

Provide mechanisms to identify opportunities for improvement in care and services, and use the results of these activities to develop "lessons learned”.

Federal Legislative requirements expect the Planning Council to review and utilize service outcome and quality assurance data of services in the prioritization and allocation

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of Ryan White Care Act Title I awards for the Oakland EMA. To help them fulfill this mandate, the Planning Council will continue to be educated on the Chronic Care Model and on Quality Assurance activities for the EMA, and will continually review the Quality Management Plan, Standards of Care, and service indicators. The Planning Council will be updated on QA activities on a monthly basis throughout the three-year Plan period. In addition, consumers will attend QA training offered by AETC and OAA in order to increase their understanding of CQI implementation. Consumers will also be involved in implementing CQI activities of specific emphasis are the Standards of Care, and service outcome indicators. Consumers who are qualified may participate in grantees site visits, and will also assist with evaluation of QM activities in Oakland EMA.

The Continuous Quality Improvement Committee will provide ongoing input and direction on the Oakland EMA Quality Management Program and its relationship to the three-year Comprehensive HIV Plan. The Committee shall meet quarterly, or as needed to its responsibilities, and will review and update the Quality Management Plan on an annual basis; establish quality assurance processes; and conduct a variety of evaluation activities. The CQI Committee will also determine program priorities, performance measures, and identify indicators to assess and improve performance. The committee shall make recommendations to the grantee for appropriate education relating to quality improvement concepts and techniques, and shall make recommendations to the Planning Council as a whole regarding implementation of CQI- related Plan objectives and action steps. The committee will report cumulative service outcome results to the Planning Council, Executive Committee and Service Committee as well.

The Oakland EMA will build upon lessons learned through its successful collaboration with the Institute for Health Care Improvement (IHI) by leading its own series of learning sessions focused on improving care for people infected with HIV using the Chronic Care Model and PDSA Cycle. These training sessions will incorporate training-related components of the Three-Year Plan wherever relevant or applicable. The training sessions will help increase provider knowledge regarding the chronic care model and PDSA Cycle, and provide guidance to staff. As a result the service providers will be able to apply the models to improve their delivery of care to HIV/AIDS infected clients.

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ENDNOTES

1 US Census Bureau, California QuickFacts, Alameda and Contra Costa Counties. Revised February 1, 2005, http://quickfacts.census.gov/qfd/states/06000.html 2 California State Department of Finance, Cumulative incidence of AIDS as of 4/30/2005. Alameda County 474.1 and Contra Costa 248.6 cases per 100,000. 3 Key sources of HIV/AIDS statistics for this section- in addition to those provided by the US Centers for Disease Control and Prevention for this application- include Alameda County Public Health Department, Division of Communicable Disease Control and Prevention, AIDS Epidemiology Report, Alameda County California, 1980- 2004, Oakland, CA June 2005; and Contra Costa Health Services Public Health Communicable Disease Program, HIV/AIDS Epidemiology Report, Martinez, CA, July 2005. 4 Estimated using 2003 US midpoint PLWH/A estimates adjusted for Oakland EMA non-names HIV reporting. 5 HIV Prevalence calculated based on 2003 CDC midpoint estimate of PLWH/A in USA, the proportion of Oakland EMA PLWA in relation to US PLWA, the calculated estimate of PLWH by subtracting PLWA in Oakland EMA, adjusted to 2004 using Alameda and Contra Costa County HIV Non-Names reports through 12/31/04. 6 Millet, D., Malebranche, D. et al, “Focusing ‘Down Low’: Bisexual Black Men, HIV Risk and Heterosexual Transmission”. Journal of the National Medical Association. 2005; 97: 528-598. 7 California and the HIV/AIDS Epidemic 2002. California Dept. of Health Services. http://www.dhs.ca.gov/ps/ooa/Reports/SOS/PDF/SOS2001.pdf 8 AIDS Incidence for EMA aggregated from Alameda and Contra Costa Counties yearly epidemiological reports. 9 Syphilis and Chlamydia statistics drawn from California Department of Health Services and California Conference of Local Health Officers, County Health Status Profiles 2005, Sacramento, CA, April 2005. http://www.dhs.ca.gov/hisp/chs/phweek/cprofile2005/Profile2005.pdf 10 Gonorrhea statistics from “Gonorrhea, cases and rates, California Counties and Selected City Health Jurisdictions 2000-2004”, California Dept. of Health Services. http://www.dhs.ca.gov/ps/dcdc/STD/docs/Gonorrhea%202000- 2004%20Provisional%20Tables.pdf 11 TB statistics from California Department of Health Services and California Conference of Local Health Officers, County Health Status Profiles 2005, Sacramento, CA, April 2005. http://www.dhs.ca.gov/hisp/chs/phweek/cprofile2005/Profile2005.pdf 12 Correspondence, Ms Susan Black Hepatitis C Coordinator Alameda County Public Health. 13 Urban Health Study of the University of California at SF, review of IDU and HCV research projects http://www.ucsf.edu/uhs/program.html 14 Heredia, C., “High Hepatitis C rates in Bay Area: UCSF study finds possible links to herpes, cocaine use”, San Francisco Chronicle, Tuesday, April 2, 2002. 15 Based on estimated 1.5% of total 1998 Oakland EMA population over 18 (n=1,552,899) being active drug injectors. Percentage derived from 1997 Calif. Dept. of Health Services projection of 2% incidence of active drug injection in SF and LA Counties. 16 California Department of Alcohol and Drug Programs, Community Indicators of Alcohol and Drug Abuse Risk, Alameda County and Contra Costa County. Prepared by Center for Applied Research Solutions, Folsom, CA, 2004. 17 National Low Income Housing Coalition. “Least Affordable Counties” 2004. http://www.nlihc.org/oor2004/table3.htm 18 “Alameda County-Wide Homeless Continuum of Care”, Alameda County Continuum of Care Working Group, April 1997and “Contra Costa County HIV/AIDS Housing Plan”, Contra Costa County Community Development Department, December 1996. 19 Ibid. 20 Percentages based on estimated uninsured rates of 14% of total population in Alameda County and 13% of total population in Contra Costa County. Data Source: “The State of Health Insurance in California, 1998, University of California, Los Angeles Center for Health Policy Research, January 1999. 21 Insure the Uninsured Project, Overview of the Uninsured, Alameda County, 2002, A Report funded by the California Wellness Foundation and the California Endowment, May 2003. 22 Venturi Staffing Partners, Alameda County and Contra Costa County Unemployment Rates, September 2003, www.venturi-staffing.com/ca_ui.shtml

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23 Oakland EMA 2004 Needs Assessment produced by All Health Care of Oakland, CA. 24 US Centers for Disease Control and Prevention, Advancing HIV Prevention Progress Summary, April 2003 - September 2005, Rockville, MD, September 2005, http://www.cdc.gov/hiv/prev_prog/AHP/resources/factsheets/Progress_2005.pdf 25 Battjes, R, Sloboda, Z. “The Context of HIV Risk Among Drug Users and Their Sexual Partners”, NIDA Research Monograph Series, #143. US Dept. Health and Human Services, 1994, p. 82. 26 California Department of Alcohol and Drug Programs, Community Indicators of Alcohol and Drug Abuse Risk, Alameda County and Contra Costa County. Prepared by Center for Applied Research Solutions, Folsom, CA, 2004. 27 Davis, Lois and Pacchiana, S, "Health Profile of the State Prison Population and Returning Offenders: Public Health Challenges," Journal of Correctional Health Care, Fall 2003. Rand Research Brief, http://www.rand.org/publications/RB/RB6013/

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