Transcript Document

Ryan White Part A: Harm
Reduction Services
Integration of Care Committee
HIV Planning Council of New York City
Danny Stewart
Safe Horizon
Streetwork Program
May 20, 2011
Streetwork Programs
Streetwork started in 1984 as a street-outreach program in
Times Square for homeless and street-involved youth and
young adults to age 24.
Streetwork has grown to include:
•Drop-In Centers
•Uptown
•LES
•Residential (emergency shelter)
•Harlem
•Midtown
•Outreach (late night, 5 boroughs)
Mission Statement
We are committed to reaching out to homeless and
disenfranchised youth offering them respite from hunger,
cold, loneliness and fear, and the opportunity to reclaim
or maintain a sense of dignity and self-worth. Our goal is
to extend ourselves to these young people through our
presence on the streets, through the services we
provide, and through the love we are willing to express.
With every meal, medical appointment, referral, condom
and group we offer, we communicate to our clients our
concern for their lives and our belief in their potential.
Our mission is to act as a catalyst for their selfempowerment.
Streetwork Clients
Risk Factors
• Homelessness
• Trauma & violence
• Mental health issues
• Survival sex work
• Substance use
Streetwork Client Data
January 1—December 31, 2010
Total Drop-In Center Clients: 994
Average daily attendance: 77
5%
41%
54%
Male
Female
Transgender
Demographics:
Substance Use
87%
Survival Sex
87%
LGBT
42%
Mental Health Issues
HIV +
33%
5%
Demographics
March 1, 2010—February 28, 2011
31 clients enrolled in HRR—all HIV positive
Retention rate (July 1, 2010—March 31, 2011): 50%
5%
25%
20%
70%
15%
65%
African American/Black
Hispanic/Latino
White
Male
Female
Transgender Female
Effective Approaches in Working with
Youth
Positive Youth Development—focuses
on a strengths perspective to promote healthy,
responsible, and compassionate choices
1. Building strengths or assets—protective
factors (resiliency) that impact risks
2. Youth engagement, voice, involvement
3. Relationship building
4. Long term involvement
Positive Youth Development
•
Assets Coming Together (ACT) for Youth Downstate Center for Excellence,
ACT for Youth Upstate Center of Excellence. (2003). A Guide to Positive
Youth Development. New York: Mount Sinai Adolescent Health Center.
Website: www.actforyouth.net
•
Birkhead, G.S., Kreipe, R.E., Klein, S.J. (Supplement Eds.) Journal of
Public Health Management and Practice. 2006, November (Supplement).
Supplement focus: Improving public health through youth development.
•
Dotterweich, J. (2006) Positive Youth Development Resource Manual.
Ithaca, NY: Cornell University, ACT for Youth.
•
Goggin, S., Powers, J., Spano, S. (2002). Profiles of Youth Engagement
and Voice in New York State: Current Strategies. Based upon the work
supported by the Cooperative State Research, Education, Extension
Services, U.S. Department of Agriculture, and the Cooperative Extension
Service, Cornell University, Children, Youth and Family At Risk Program.
Effective Approaches in Working with
Youth
Client-Centered Practice—individuals
have the capacity to change and grow through
empathy and unconditional acceptance. The focus
is on the client’s interests & concerns.
1. Honor and respect
2. Compassionate responses
3. Clients can make informed decisions
4. Non-judgmental approach
Client-Centered Practice
•
Grieder D & Theis G (2008). Wisconsin: leading the way to person-centered
planning in community-based health International Journal of Psychosocial
Rehabilitation. 12(2), 111-114.
•
Finfgeld, D. L. (2004). Empowerment of individuals with enduring mental
health problems: results from concept analyses and qualitative investigations.
Advances in Nursing Science, 27(1), 44-52.
•
Markland, D., Ryan, R. M., Tobin, V. J., & Rollnick, S. (2005). Motivational
interviewing and self determination theory. Journal of Social & Clinical
Psychology, 24(6), 811-831.
•
Meichenbaum, D., & Turk, D.C. Facilitating Treatment Adherence. (1987).
Kluwer Academic Publishers.
•
Wahl, Chris. Gregoire, J.P., Koon, T., et.al. (2004). Concordance, compliance
and adherence in health care: closing gaps and improving outcomes.
Healthcare Quarterly, 8(1) 2005: 65-70.
Youth & HIV Testing
• HIV positive results—youth tend to
engage in some level of sexual risk
behavior.
Murphy, D., Moscicki, A., Vermund, S., Muenz, L. Psychological distress among HIV
positive adolescents in the REACH study: effects of life stress, social support and
coping. Journal of Adolescent Health. 27 (6), Dec. 2000, 391-398.
Murphy, D., Durako, S., Moscicki, A., Vermund, S., Ma, Y., Schwarz, D., Muenz, L.
No change in health risk behaviors over time among HIV infected adolescents in
care: role of psychological distress. Journal of Adolescent Health. 29 (Suppl. 3),
Sept. 2001, 57-63.
Rotheram-Borus, M., Lee, M., Zhou, S., O’Hara, P., Birnbaum, J., Swendeman, D.,
Wright, W., Pennbridge, J., Wright, R. Variation in health risk behavior among youth
living with HIV. AIDS Education and Prevention. 13 (1), Feb. 2001, 42-54.
Effective Interventions
Case Management—a formal and
systematic multi-step process designed to assess
the needs of a client to ensure access to needed
services. It strives to ensure that clients with
complex needs receive timely coordinated
services. The case manager functions as an
advocate for services for the client, with particular
emphasis placed on the client’s self sufficiency in
the community.
Case Management
•
Gardner, LI, Metsch, LR, Anderson-Mahoney, P, Loughlin, AM, del Rio, C, Strathdee,
S, Sansom, SL, Siegal, HA, Greenberg, AE, Holmberg, SD (2005). Antiretroviral
Treatment and Access Study Group. Efficacy of a Brief Case Management
Intervention to Link Recently Diagnosed HIV-Infected Persons to Care. AIDS.
19(4):423-31.
•
Katz, MH, Cunningham, WE, Mor V, Andersen, RM, Kellogg, T, Zierler, S, Crystal,
SC, Stein, MD, Cylar, K, Bozzette, SA, Shapiro, MF. (2000). Prevalence and
Predictors of Unmet Need for Supportive Services Among HIV-Infected Persons:
Impact of Case Management. Medical Care. 38(1):58-69.
•
Katz, MH, Cunningham WE, Fleishman, JA, Andersen, RM, Kellogg, T, Bozzette, SA,
Shapiro, MF. (2001). Effect of case management on unmet needs and utilization of
medical care and medications among HIV-infected persons. Annals of Internal
Medicine. 16;135(8 Pt 1):610-2.
•
Kushel, MB, Colfax, G, Ragland, K, et al. (2006). Case management is associated
with improved antiretroviral adherence and CD4+ cell counts in homeless and
marginally housed individuals with HIV infection. Clinical Infectious Diseases.
43(2):234-242.
Effective Interventions
Sexuality and Sex Education—
process of acquiring information and forming
attitudes and beliefs about sex, sexual
orientation, relationships and intimacy. It is
also about developing individual’s skills so
that they make informed decisions, and feel
confident and competent about acting on
these decisions.
Sexuality and Sex Education
•
Haglund, K. Recommendations for sexuality education for early
adolescents. (2006). Journal of Obstetrics, Gynecology and Neonatal
Nursing. 35(3):369-75.
•
Robinson, BB, Uhl, G, Miner, M, Bockting, WO, Scheltema, KE, Rosser,
BR, Westover, B. (2002). Evaluation of a sexual health approach to prevent
HIV among low income, urban, primarily African American women: results
of a randomized controlled trial. AIDS Education and Prevention. 14(3 Suppl
A):81-96.
•
Shapiro, K, Ray, S. (2007). Sexual health for people living with HIV.
Reproductive Health Matters. 2007;15(29 Suppl.):67-92.
•
UNAIDS. (1997). Impact of HIV and Sexual Health Education on the Sexual
Behavior of Young People: A Review Update. Report prepared by UNAIDS,
The Joint United Nations Programme on HIV/AIDS for World AIDS Day.
Homelessness, HIV & Youth
• Homelessness/unstable housing is one of the most important
barriers to use of ART
• High viral load, recent OI, and HIV hospitalization are associated
with homelessness/unstable housing
• Lack of housing creates/maintains pervasive context of risk makes it
hard to avoid risky situations or to use risk-reducing tools
• Findings suggest that the condition of homelessness—and not
simply traits of homeless individuals—influences risk behaviors and
service utilization.
•
Aidala, Angela. (2008). Housing is HIV prevention and care. HIV Center for Clinical
and Behavioral Studies. Presentation: April 10, 2008.
Homelessness, HIV & Youth
• Homeless youth need more than treatment for substance
use.
• “While the CRA program was successful, I think what we
do in treatment is less important than the process. The
content is not as important as having these teens come in
and talk to a therapist and develop a new, positive
experience with an adult. That is what they really need.”
• Slesnick, N., Prestopnik, J. L., Meyers, R. J., & Glassman,
M. (2007). Treatment outcome for street-living, homeless
youth. Addictive Behaviors; 32:1237–1251.
Homelessness, HIV & Youth
• Among YMSM—homelessness, rather
than knowledge, attitude, or intention,
seemed to predict both drug and sexual
risk.
• Clatts, MC, Goldsamt, LA, Yi, H. (2005). Drug and sexual risk in
four men who have sex with men populations: evidence for a
sustained HIV epidemic in New York City. Journal of Urban
Health; 82 (1, Supplement 1): i9-i17.
Homelessness, HIV & Youth
• Few YMSM who have become homeless have used drugs prior to
their becoming homeless.
• Involvement in the street economy, including sex work and drug use,
are better understood as adaptations to homelessness, rather than
causes of it.
• structural interventions—systemic approaches to more effective
means of reaching, engaging, and retaining homeless YMSM in
shelter services and permanent housing programs—should be
central considerations in formulating HIV and other public health
interventions targeted to this population.
•
Clatts, MC, Goldsamt, L, Yi, H, Gwadz, MV (2005). Homelessness and drug abuse
among young men who have sex with men in New York City: A preliminary
epidemiological trajectory. Journal of Adolescence, 28(2): 201-214.
Homelessness, HIV & Youth
• Homeless youth need an ongoing safety net.
• Youths’ need for a safety net are not short-term, but
intended to provide assistance over an extended period
of time (12-33 months) until youth become stably housed.
• There is no model that anticipates that the youth will be
able to protect themselves from HIV without a holistic
approach that supports the youths’ development and
capacity building.
•
Arnold, EM, Rotheram-Borus, MJ. (2009). Comparisons of prevention
programs for homeless youth. Prevention Science;10(1):76-86.
Conclusions
• One-size fits all interventions are not effective—
especially with youth.
• For maximum effectiveness, evidence-based
programming must include a long-term investment
with an emphasis on a counseling relationship and
creating stability with homeless HIV + youth.
• Behavior change occurs in the context of a
relationship—where youth are supported and
unconditional love and acceptance are conveyed.
• Public health strategies are most effective when they
involve a strong collaboration with the community
Contact Information
Danny Stewart
Director of Operations
Streetwork
Safe Horizon
646-214-3806
[email protected]