Transcript Emerging Populations with Special Needs

Overview Populations
with Special Needs
HIV Planning Council
Needs Assessment Committee
June 16, 2010
Jan Carl Park, MA, MPA
Nina Rothschild, MA, MPH, DrPH
Source: NY EMA FY 2010 Part A Grant Application, October 30, 2009 www.nyhiv.org
1
Women of Color
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Women of Color: Epidemiology
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The number of AIDS cases among women increased from
roughly 21% in 1990 to 29% in 2008.
Women account for 30% of PLWHA in the EMA, including
31% of new AIDS diagnoses in 2007-2008.
Nine out of 10 women living with HIV/AIDS are women of
color.
Among women of childbearing age (ages 15-44), Blacks are
nearly 15 times more likely than whites to be HIV-infected.
The densest concentrations of female HIV/AIDS cases are in
the City’s most impoverished neighborhoods – the South
Bronx, Central Harlem, and Central Brooklyn.
Women face unique challenges to health care access and
continuity. Nearly one-third (29%) of NYC women
diagnosed with HIV (non-AIDS) in 2007-2008 failed to
enter care within three months of their positive HIV test.
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Women of Color: CHAIN Study
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Women with HIV have particular health care and
social service needs not typically shared with
men, such as the need for appropriate
gynecological services, child care and familycentered services.
Women enrollees in CHAIN are more than twice
as likely as heterosexual male study participants
to experience domestic violence, which is
associated with poor treatment adherence.
Compared with other PLWHA participating in the
longitudinal cohort study, HIV-infected women in
CHAIN are significantly more likely to report
lacking sufficient money in the household for
utilities, food and clothing.
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Women of Color: CHAIN Study
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Among HIV-positive women in the CHAIN study
who need professional mental health services,
28-33% (depending on the location of the cohort
– NYC or Tri-County) are not receiving them.
Also depending on the location of the cohort, 4652% of HIV-infected women in the study who
require substance abuse services are not being
served by such programs.
Women living with HIV have an age-adjusted
death rate that is 23% higher than their male
counterparts.
Women in NYC tend to be older than males when
they are diagnosed with HIV, but on average they
die at an earlier age.
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Women of Color
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Between March and August 2009, HIVinfected mothers on average required 56%
more Part A services than the typical PLWHA.
Women with HIV/AIDS are particularly heavy
users of home care, supportive counseling
and family stabilization services.
As many HIV-positive women have
childrearing responsibilities, women used
nearly two-thirds more food and nutrition
services in the first half of 2009 than men.
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Women of Color: Part A Funded
Services
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Because women with HIV experience unique
barriers to health care, the EMA invests in a
range of women-focused initiatives that expand
service access.
While females represent 31% of all PLWHA in
FY08, they accounted for 41% of Part A clients.
Extrapolating from per-client estimates of
expenditures, the EMA estimates that women
represent more than $34 million in base Part A
spending alone, including more than $8.5 million
beyond the spending that would be anticipated if
women represented the same percentage of Part
A clients as they do of PLWHA overall.
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Young Men of Color
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www.citadeloflove.org
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Young MSM of Color: Epidemiology
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As of December 2008, 2,865 MSM of color
between ages 13-29 were living with diagnosed
HIV/AIDS in NYC.
The rate of growth in this population is
exceptionally high, with 1,163 young MSM of
color having been diagnosed with HIV in 20072008.
Young Black MSM (18-29) in NYC are nearly four
times more likely than white or Hispanic MSM to
be infected with HIV.
From 2001 to 2008, HIV diagnoses among young
MSM (under age 30) in NYC increased by 46%,
with the number of new diagnoses rising by 68%
among MSM ages 13-19.
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Young MSM of Color
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Young MSM of color are often less likely than many other groups
to use health care services. For example, because relatively few
young people suffer from the chronic health conditions that are
common in older adults, utilization of preventive, diagnostic and
chronic disease management services may be a lower priority for
young people.
Most HIV-positive young MSM of color live in low-income
neighborhoods, with a significant percentage residing in the
Bronx, the country’s poorest urban county.
Unemployment is high among young MSM of color, and
opportunities for vocational training are typically limited.
According to surveys conducted by DOHMH, young MSM of color
frequently abuse drugs and alcohol, which may reduce treatment
adherence and regular utilization of HIV primary care.
A disproportionate share of the estimated 3,800 homeless young
people in the EMA are MSM of color, and the chaotic life conditions
associated with unstable housing significantly increase the risk of
HIV infection and reduce utilization of needed services.
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Young MSM of Color
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Many young MSM of color experience acute
trauma and mental health challenges that may
further diminish health care access.
A recent multi-city survey of HIV-positive MSM
(including in NYC) found that 47% reported
having experienced childhood sexual abuse, with
such abuse 2.6 times and 1.8 times as likely to
be reported by Hispanic and Black MSM,
respectively, as among whites.
According to a nationwide survey of health
departments and AIDS program officers, the
stigma associated with homosexuality and
discriminatory attitudes of providers frequently
impede HIV service access for Black MSM.
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Young MSM of Color: Services
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Because they face such severe impediments to
favorable medical outcomes, young MSM of color
have especially acute service needs. Among MSM
diagnosed with HIV, Black and Hispanic men are
more likely than whites to receive their AIDS
diagnosis late in the course of infection.
Compared to MSM overall, MSM of color are less
likely to be in HIV care within three months of
their HIV diagnosis.
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Young MSM of Color: Part A
Funded Services
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To address the growing epidemic among young
MSM of color, Part A funds numerous programs
that specifically address the unique needs of this
population, including services for runaway youth
and a clinic-based program in Manhattan for
young MSM of color that returns an average of
four clients a week to HIV primary care through
intensive home visits and community outreach.
The FY10 plan also includes an innovative new
youth outreach initiative that will target young
MSM and other high-risk youth, identifying
people living with or at high risk of HIV under the
age of 24 and linking them to care and
treatment.
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Men Who Have Sex With Men
(MSM)
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MSM: Epidemiology
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Nearly 35,000 MSM are living with HIV in
the EMA.
Since 2001, while the share of new HIV
diagnoses among IDUs has fallen, the
proportion of new HIV cases among MSM
has steadily increased.
In 2007-2008, MSM accounted for 44% of
all new adult and adolescent HIV
diagnoses in NYC.
Among newly diagnosed MSM, roughly
equal numbers of Blacks, Hispanics and
whites are represented.
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MSM: CHAIN Study
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33% of MSM of color in the CHAIN study who need
antiretrovirals were not accessing treatment.
Three out of four (75%) MSM of color participants in
the cohort study who need substance abuse services
are not receiving them, while 69% of those requiring
supportive mental health services are not utilizing
such services.
Forty percent of MSM of color who are homeless or
unstably housed are not obtaining permanent housing
assistance.
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MSM: Part A Funded Services
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The intensive service needs of low-income MSM
significantly increase the cost and complexity of
the EMA’s HIV response.
In 2008-2009, MSM accounted for 28% of EMA
recipients of HIV uninsured care services,
representing more than $55 million in outlays for
HIV-related medications and physicians services
(covered through a combination of Part A, Part B,
and State tax levy).
On average, MSM of color use 56% more Part A
services, or $2,004 per client, than the average
Ryan White client ($1,285).
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MSM: Part A Funded Services
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MSM recipients of Part A services are
predominantly Black and Hispanic.
MSM of color are more likely than whites to be
low-income and less likely to have private health
coverage.
The enduring stigma associated with
homosexuality in many parts of the EMA, as well
as limited primary care service options
specifically designed for MSM of color, limits
health care utilization by this group of high-need
PLWHA.
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Transgender Individuals
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Transgender Individuals
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Transgender individuals represent another part of the
broader lesbian/gay/bisexual/transgender (LGBT)
community that faces heightened HIV risk and
particular service challenges.
An estimated 12,500 New Yorkers have undergone
some form of medical gender transition.
A recent meta-analysis of HIV-related studies
involving transgender women (i.e., individuals who
were assigned a male sex at birth but prefer a female
identity) found overall HIV prevalence of 28% in this
population, with consistently higher HIV prevalence
detected among people of color.
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Transgender Individuals
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The recently completed New York Transgender Project study
found HIV prevalence of 50% among transgender women of
Latin American origin and 48% prevalence among Black
transgender women.
In a DOHMH survey of NYC’s house ball community – which
is 95% Black or Hispanic and includes considerable
numbers of transgender individuals – 17% of study
participants tested HIV-positive.
Studies indicate that transgender women on average
engage in higher levels of risk behavior – such as
unprotected anal intercourse and injection drug use – than
MSM.
Transgender individuals are not only vulnerable to HIV
infection as a result of unprotected sexual behavior, but
also often as a result of needle sharing for the
administration of hormones.
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Transgender Individuals
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According to a recent survey of male-to-female
transgender individuals in NYC, the shortage of
transgender-friendly and transgenderknowledgeable health providers represent major
barriers to care.
Transgender individuals frequently suffer from
homelessness or housing instability, lack of
income, and harassment by law enforcement
authorities.
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Transgender Individuals: Part A
Funded Services
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Part A supports programs specifically designed
for MSM and transgender PLWHA and delivered
by organizations grounded in these communities.
• Part A supports food and nutrition, treatment adherence
and psychosocial support at a Manhattan-based agency
with citywide reach that was founded by MSM.
• Part A supports the largest safety-net medical services
provider in NYC’s LGBT community.
• Part A supports a contractor in the South Bronx which
recently hired a transgender program coordinator to
oversee outreach and the tailoring of services to reach
low-income transgender PLWHA.
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PLWHA Over 50
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PLWHA Over 50: Epidemiology
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As a result of medical advances, PLWHA are living
longer.
In 2008, nearly 40,000 PLWHA in NYC were at least
50 years old.
• More than 11,000 PLWHA in NYC are older than 60,
including more than 2,000 who are 70 or above.
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Between 2001 and 2008, the percentage of PLWHA
who were 50 years or older rose from 21% to 37%.
People older than 50 accounted for 25% of new AIDS
diagnoses in NYC in 2008 and for 48% of all deaths
among PLWHA.
Three-quarters of PLWHA over 50 are Black or
Hispanic, and older PLWHA are heavily concentrated in
Lower Manhattan and in the low-income
neighborhoods of Harlem and the South Bronx.
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PLWHA Over 50: Epidemiology
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Older individuals also constitute an important and often underrecognized component of the newly diagnosed; in 2008,
people over 50 represented 17% of new HIV diagnoses in NYC.
Among newly diagnosed persons over age 50, 82% are Black
or Hispanic.
Older individuals are often diagnosed extremely late in the
course of infection, frequently because they may lack an
understanding of their vulnerability to infection.
In 2007, 35% of newly diagnosed individuals ages 50-59, and
43% of newly diagnosed individuals over 60, were
subsequently diagnosed with AIDS within one month of their
positive HIV test.
Even though newly diagnosed persons over 50 are typically
much sicker than younger people who receive a positive HIV
test result, nearly one in three (32%) persons over age 50
have still not entered HIV primary care within three months of
diagnosis.
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PLWHA Over 50
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As PLWHA age, effective medical management of
HIV requires the ability to manage conditions
commonly associated with aging.
Among PLWHA over age 50 who died in 2007,
44% died of a non-HIV-related cause (compared
to younger AIDS deaths, 23% of whom died from
non-HIV-related causes).
The need to simultaneously manage HIV and
numerous other health problems significantly
increases the cost and complexity of care.
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PLWHA Over 50: Part A Funded
Services
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Barriers to care for PLWHA over 50 include insufficient
access to providers capable of managing the
comprehensive health problems of older adults, as
well as the common problem of social isolation.
In recent years, the EMA has made concerted efforts
to focus services on PLWHA over age 50.
Between FY06 and FY08, the number of clients over
age 50 reached by Part A services increased by more
than 50%, exceeding 19,000 in FY08.
For HIV medications and primary services only –
which are jointly funded by Part A, Part B, and State
tax levy – PLWHA over age 50 accounted for an
estimated $62 million in expenditures between April
2008 and March 2009.
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Immigrants
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Immigrants: Epidemiology
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NYC is a major portal of entry to the U.S. and a
primary destination for immigrants who enter the
U.S. elsewhere.
More than 21,000 PLWHA in the EMA – nearly
one in five – are foreign-born.
Infections among immigrants are rapidly rising.
The percentage of new HIV diagnoses among
foreign-born New Yorkers increased from 17% in
2001 to 27% in 2006.
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Immigrants
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Immigrants living with HIV frequently confront
overwhelming barriers to care.
Often discouraged from seeking services due to
language barriers or fear of deportation, many
immigrants lack access to basic HIV/AIDS
information.
Linguistic barriers often impede health care
access; according to a recent national survey,
Spanish-speaking Hispanics have far worse
access to care and medical outcomes than
English-speaking Hispanics.
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Immigrants
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In many immigrant communities, the stigma
associated with HIV, homosexuality, and drug use
deters individuals from seeking counseling,
voluntary testing, or HIV/AIDS medical services.
Isolation from friends and family frequently
contributes to high levels of substance abuse and
depression among immigrants, further interfering
with healthy behaviors and service utilization.
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Immigrants
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As a result of barriers to health care utilization,
foreign-born individuals newly diagnosed with
HIV in 2007-2008 were 50% more likely than
their U.S.-born counterparts to receive an AIDS
diagnosis within 31 days.
Foreign-born newly diagnosed persons with HIV
in NYC are also less likely than U.S.-born persons
to have entered HIV primary care within three
months of their diagnosis and are significantly
more likely to be co-infected with TB than their
US-born counterparts.
Immigrant PLWHA have an age-adjusted death
rate nearly one-third higher than white PLWHA.
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Immigrants
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The large number of HIV-infected immigrants in
the EMA increases the cost and complexity of
responding to the epidemic.
On average, HIV-positive immigrants used 33%
more Part A services between March and August
2009 than PLWHA as a whole, representing an
average per-client expenditure of Part A funds of
$1,708 (compared to the average of $1,285 for
all Part A clients).
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Immigrants: Part A Funded Services
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To address the multiple barriers to health care
access and continuity faced by diverse immigrant
communities, Part A funds a broad range of
services focused on immigrants living with HIV.
Part A funds diverse services specifically designed
for specific immigrant communities from the
Caribbean, South America, sub-Saharan Africa,
and Asia and the Pacific Islands.
Part A funds service providers that have the
capacity to deliver services in more than 50
languages.
For HIV-positive immigrants who are
undocumented, Part A is the sole source of
funding for HIV care and treatment.
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AOD Populations
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recovery.stantonstreet.com
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AOD Populations
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The EMA uses federal, state and local funding to support a
network of diverse alcohol and drug treatment services in
the EMA.
Such services include medically managed drug
detoxification, adult outpatient services, intensive and
community residential treatment, and drug substitution
therapy (e.g., methadone, buprenorphine).
Substantial unmet need exists for methadone maintenance,
in-patient rehabilitation and residential services.
In addition, many mainstream substance abuse treatment
programs fail to address the unique medical and social
needs of MSM, pregnant women, immigrants and other
groups with high HIV prevalence.
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AOD Populations
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To address the related epidemics of substance
addiction and HIV/AIDS, the EMA in FY10 will
allocate $12 million in base funding for clientcentered, low-threshold substance abuse
programs that are not covered by other payment
sources.
In FY10, Part A will support more than 17,000
PLWHA in addressing their substance abuse
behaviors through harm reduction, recovery
readiness and relapse prevention services.
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AOD Populations
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More than three quarters (76.2%) of participants
in the CHAIN study who received drug and
alcohol treatment services in 2006-2007 reported
being very satisfied with the quality of such care.
For substance-using PLWHA enrolled in the
CHAIN cohort, receipt of drug treatment is
strongly associated with increased utilization of
appropriate medical services.
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AOD Populations: Part A Funded
Services
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The EMA in recent years has increased its efforts to
co-locate substance abuse services in settings that
provide other essential services, such as primary
medical care, housing assistance, and mental health
services.
For example, Part A supports physicians to provide
substance abuse assessments and referrals to PLWHA
living in single-room occupancy hotels.
To address the unique needs of key sub-populations,
Part A programs have implemented a range of
innovative service models, including a Queens-based
program for young PLWHA that uses recreational
activities to attract clients to needed services.
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Cultural and Linguistic
Competence
For foreign-born PLWHA, Part A funds
an array of services in more than 50
languages.
 All Part A programs are required to
have translation services available
for non-English-speaking clients.
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