San Antonio TGA/HSDA 2017-2021 Integrated Comprehensive HIV/AIDS Services Plan San Antonio Transitional Grant Area (Bexar, Comal, Guadalupe, and Wilson Counties) and Health Services Delivery Area (Bexar, Comal, Guadalupe, and Wilson, Atascosa, Bandera, Frio, Gillespie, Karnes, Kendall, Kerr, and Medina Counties) Integrated HIV Prevention and Care Plan 2017-2021 1 | P a ge San Antonio TGA/HSDA 2017-2021 Integrated Comprehensive HIV/AIDS Services Plan Contents Executive Summary .................................................................................................................................... 3 Introduction ................................................................................................................................................. 4 Section I: SATGA/HSDA Statement of Need ............................................................................................ 7 A. San Antonio TGA/HSDA Epidemiologic Overview ..................................................................... 7 B. San Antonio TGA/HSDA HIV Care Continuum ......................................................................... 41 C. San Antonio TGA/HSDA Financial and Human Resource Inventory ......................................... 46 D. San Antonio TGA/HSDA Needs, Gaps, and Barriers .................................................................. 65 E. San Antonio TGA/HSDA Data: Access, Sources, and Systems .................................................. 71 Section II: Integrated HIV Prevention and Care Plan ............................................................................... 74 A. Integrated City-Only HIV Prevention and Care Plan................................................................... 74 B. Collaborations, Partnerships, and Stakeholder Involvement ........................................................ 93 C. People Living With HIV (PLWH) and Community Engagement.............................................. 100 Section III: Monitoring and Improvement .............................................................................................. 104 Appendix A: Commonly Used Terms .................................................................................................... 107 Appendix B: Financial Resource Inventory Survey ............................................................................... 109 Appendix C: The San Antonio TGA/HSDA Resource Guide, 2015 ...................................................... 111 Appendix D: TDSHS ARIES Letter, May 20, 2016 ............................................................................... 171 Appendix E: Stakeholder Activity Worksheet #1 .................................................................................. 172 Appendix F: Letter of Support and Concurrence .................................................................................... 174 2 | P a ge San Antonio TGA/HSDA 2017-2021 Integrated Comprehensive HIV/AIDS Services Plan Executive Summary Bexar County Department of Community Resources Ryan White Program (RWP) Administrative Agency (AA), the San Antonio Ryan White Planning Council (PC) and Integrated HIV Prevention and Care Plan Stakeholder Group (HPCG) presents this new City Only Integrated HIV Prevention and Care Plan, which responds to the planning guidance published by the Centers for Disease Control and Prevention (CDC) and the Health Resources and Services Administration (HRSA) in June 2015. This plan serves as the guide for the integrations of prevention and care services for the San Antonio (SA) Transitional Grant Area (TGA) and Health Services Delivery Area (HSDA). The National HIV/AIDS Strategy Updated to 2020 (NHAS) outlines the national vision and action plan for curtailing the HIV epidemic and improving health outcomes of all people living with HIV, including AIDS (PLWH) in the United States. The SATGA/HSDA’s plan embraces this vision: The United States will become a place where new HIV infections are rare, and when they do occur, every person, regardless of age, gender, race/ethnicity, sexual orientation, gender identity, or socio-economic circumstance, will have unfettered access to high quality, life-extending care, free from stigma and discrimination. (NHAS, August 2015) The SATGA/HSDA City Only Integrated HIV Prevention and Care Plan articulates this vision locally and presents a roadmap for HIV services over the next five years, identifying specific goals, objectives, and activities that are needed to radically interrupt transmission of HIV in the SATGA/HSDA and improve health outcomes of all PLWH. SATGA/HSDA’s HIV Continuum of Care, which includes four HIV outcome measures (i.e., linked to care, retained in care, antiretroviral therapy and virally suppressed). This plan has become a cornerstone for planning and provides a useful tool for measuring SATGA/HSDA progress and success in achieving NHAS goals. This plan is divided into three sections: (1) SATGA/HSDA Statement of Need, (2) Integrated HIV Services Plan; and (3) Monitoring and Improvement. The SATGA/HSDA Statement of Need describes the HIV epidemic in the 12 county area (i.e., Bexar, Comal, Guadalupe, Wilson, Atascosa, Bandera, Frio, Gillespie, Karnes, Kendall, Kerr, and Medina Counties); social determinants of health and their impact on PLWH; available financial resources for services delivered within the SATGA/HSDA; HIV workforce capacity needs; and the needs, barriers, and gaps of persons living with and at high risk of acquiring and/or transmitting HIV to others. This section also includes a description of the current and planned use of data to improve prevention and care services. The Integrated HIV Services Plan describes SATGA/HSDA’s specific goals, measurable objectives, planned strategies, and core activities that are needed to curtail HIV transmission in the SATGA/HSDA and improve the health and well-being of all PLWH. These are closely aligned with the vision and goals articulated in the NHAS. This section also describes the collaboration of key stakeholders and the engagement of PLWH in the planning process. Lastly, the monitoring section outlines a specific method for monitoring progress of measurable objectives and how this information will be used to improve HIV services in SATGA/HSDA. The SATGA/HSDA City Only Integrated HIV Prevention and Care Plan is a living document. The overall plan will be reviewed annually, as well as progress in achieving desired outcomes. The NHAS provides ambitious targets that SATGA/HSDA, over the next five years, will strive towards: for example, 90% of all persons living with HIV will know their serostatus, reduce new diagnoses by 25%, increase retention in care to 90%, increase viral suppression to 90%, etc. This plan represents an aggressive step forward towards ending HIV in the SATGA/HSDA. 3 | P a ge San Antonio TGA/HSDA 2017-2021 Integrated Comprehensive HIV/AIDS Services Plan Introduction Development of the SATGA/HSDA 2017-2021 City Only Integrated HIV Prevention and Care Plan, including the SATGA/HSDA Statement of Need resulted from a cooperative process between the Bexar County Department of Community Resources RWP AA, the PC, the Integrated HIV Prevention and Care Plan Stakeholder Group (HPCG), the Texas Department of State Health Services (TDSHS), and the HIV Texas Syndicate. Participants of the HPCG include the following community members: a Community Based Organization (CBO), AIDS Service Organization (ASO) not funded by Ryan White that does both prevention and linkage to care, the County Hospital District (including a RWP funded clinic), non-profit ASO that works with women and youth, PC Members, HIV Consumers, the San Antonio Police Department, the Local Public Health Planning Agency, a Rural Service Provider, Homeless Providers, LGBTQ Youth Center Provider, HIV/STI Prevention Providers, the Veterans Health Administration (VA), RWPC, RWPD, Local Substance Abuse and Mental Health Services Administration (SAMHSA) funded projects, the San Antonio Metropolitan Health District (MetroHealth), and Putting an End to Abuse through Community Efforts (PEACE) Initiative. The TDSHS Texas HIV Syndicate serves as the statewide HIV/STD community planning group for Texas. Drawing from the broad recommendations in the Texas HIV Plan and related planning documents, Syndicate members make policy, system, and practice recommendations and create tools to help regional stakeholders address HIV and other STDs with evidence-based strategies tailored to meet regional needs. The Syndicate acts in an advisory capacity to TDSHS staff and ensures that Texas maintains an inclusive and participatory planning process for the delivery of prevention and care services.1 The work group provided a strong foundation for developing the goals of this plan to: • Enhance collaborations between prevention and care funded agencies and other community organizations. • Reduce new HIV infections • Increase access to care and improve health outcomes for people living with HIV/AIDS (PLWH) • Reduce HIV-related disparities and health inequities • Achieve a more coordinated response to the HIV epidemic • Transfer knowledge and expertise throughout the community to improve HIV prevention. • Transfer knowledge and expertise throughout the community to improve HIV care and services. • Establish new community collaborations with prevention and care funded entities. • Improve the quality of HIV care and services for PLWH through an enhanced quality management program. Mission The mission of the SATGA/HSDA Integrated City Only HIV Prevention and Care Plan for 2017 – 2021 is to work in partnership with the community to provide an effective system of HIV prevention and care services that best meets the need of populations living with, affected by, or at risk for HIV. 1 Texas. (2016, January 26). Texas DSHS HIV/STD program - program improvement resources. Retrieved September 14, 2016, from https://www.dshs.texas.gov/hivstd/dir/ 4 | P a ge San Antonio TGA/HSDA 2017-2021 Integrated Comprehensive HIV/AIDS Services Plan Vision The SATGA/HSDA will become a community with a coordinated system of HIV prevention and care, where new HIV infections are rare, and, when they do occur, where every person, regardless of age, gender, race/ethnicity, sexual orientation, gender identity, or socio-economic circumstance, will have unfettered access to high-quality, life-preserving care, free of stigma and discrimination. Shared Values • Strive for a seamless system of coordinated HIV prevention and care needs. • Provide the highest quality care and services in the most cost-effective manner to reduce duplication of services. • Ensure equitable and easy access to services. • Ensure that all services are linguistically, culturally competent and responsive. • Treat all consumers with compassion and respect. This plan serves as the guide for the integrations of prevention and care services for the SATGA/HSDA and describes the HIV epidemic in the San Antonio Region which includes a 12 county area (Figure 1). Characteristics of this diverse region include: 2 • With 1.5 million residents, Bexar County, home to San Antonio, is the population center of the region. It is also the epicenter of the HIV epidemic. • The region combines urban and rural areas. Bexar County has a population density of 2,879 people per square mile. The San Antonio metro region had the sixth-fastest growth rate in the country among metros with a population of 1 million or more, growing by 2.2 percent, from 2,332,790 to 2,384,075 people last year. The metro area includes Bexar, Atascosa, Bandera, Comal, Guadalupe, Kendall, Medina and Wilson counties. 3 • The SATGA/HSDA is minority-majority areas, with 63% Hispanic residents, respectively. • In Bexar County, roughly 43% of residents speak a language other than English at home. Similar percentages are found in the other SATGA/HSDA. • Literacy rates for the SATGA/HSDA are approximately 15%. • Poverty rates for the SATGA/HSDA are approximately 20%. • The RWP AA is housed in the Bexar County Department of Community Resources and is not a local health department; therefore, must reply on collaborations with local health departments and planning agencies to strengthen prevention and care programs in the SATGA/HSDA. • The SATGA/HSDA is not a direct recipient of any CDC prevention funding, therefore the AA formulated in December 2009, along with MetroHealth and a local AIDS Service Organization (ASO), the HIV/Syphilis Testing Taskforce, which is composed of over 90 community partners providing prevention, intervention, and testing services and programs. • The AA is funded for RWP Parts A, B, and HOPWA and collaborates with locally funded RWP Parts C, D, and F. • The AA participates in the TDSHS HIV Texas Syndicate, a planning process for integrated prevention and care services across the state of Texas since 2012. 2 (QuickFacts San Antonio, Texas ) 3 Davila, V., & Writer, S. (2016, March 24). San Antonio area is no. 6 in population growth in the U.S. Among big metros. Retrieved September 14, 2016, from http://www.expressnews.com/news/local/article/San-Antonio-area-is-No-6-in-population-growth-in-7030115.php 5 | P a ge San Antonio TGA/HSDA 2017-2021 Integrated Comprehensive HIV/AIDS Services Plan Please note as of May 12, 2016, AIDS Regional Information Evaluation System (ARIES) reports have been producing inaccurate results in “Production” impacting our AA, PC, HIV prevention and care providers, and other ARIES users. The AA’s inability to complete HRSA reports (e.g. RSR since 2014) have been hindered by the ability to access reports in ARIES. AA’s have been instructed by TDSHS to not utilize reports or publish data from ARIES until further notice, including reporting to PCs and to HRSA. Any reporting that utilizes data from an ARIES report is impacted, including reports for MAI, Part A, etc. The AA has notified the Part A HRSA Project Officer and continues to seek guidance with TDSHS on this matter (see Appendix D for letter from TDSHS regarding ARIES). Because of the aforementioned issue with ARIES, the HPCG Work Group decided to use data retrieved in September 2015 for the FY 2016-2017 Part A Grant Application. The baseline data used in the Integrated HIV Prevention and Care Plan is Calendar Year (CY) 2014, therefore does not cover the recommended 5 year trending data. Please see Appendix A for a list of Commonly Used Terms 6 | P a ge San Antonio TGA/HSDA 2017-2021 Integrated Comprehensive HIV/AIDS Services Plan Section I: SATGA/HSDA Statement of Need A. San Antonio TGA/HSDA Epidemiologic Overview The Bexar County Department of Community Resources RWP AA has participated as a member of the TDSHS Texas HIV Syndicate since its inauguration in 2012. The purpose of the Texas HIV Syndicate is to reduce HIV infections in Texas by identifying strategies to enhance and expand work already being done across the spectrum of HIV prevention and treatment. Texas HIV Syndicate priority groups develop resources to advance the identified strategies across the state (Texas, 2016). a. San Antonio TGA/HSDA Jurisdictional Profile Figure 1: The San Antonio Region is divided into two areas (SATGA/HSDA) as follows: • The RWP Part A funded SATGA is comprised of four (4) counties including Bexar, Comal, Guadalupe, and Wilson. • The RWP Part B funded SAHSDA is comprised of twelve (12) counties including those in the SATGA and Atascosa, Bandera, Frio, Gillespie, Karnes, Kendall, Kerr, and Medina. At end of 2014, there were more than 6,300 SATGA/HSDA PLWH, with about 350 new HIV diagnoses a year. Both the number of PLWH and new diagnoses rose over the past five years. Black, Hispanic, and White men who have sex with (MSM) and Black heterosexual women made up more than 7 in 10 of those with HIV in the SATGA/HSDA. Both Blacks and MSM of all races/ethnicities show persistently 7 | P a ge San Antonio TGA/HSDA 2017-2021 Integrated Comprehensive HIV/AIDS Services Plan higher burdens of HIV. In 2014, almost four in five PLWH had at least one HIV-related medical visit, and more than half had achieved viral suppression, increasing health outcomes and lowering HIV transmission through viral suppression and new prevention strategies. Table 1 displays the overall trend-line for HIV/AIDS incidence and prevalence for the past three years in the SATGA/HSDA. A comparison of the demographic profile of PLWH and new HIV/AIDS cases clearly displays where the epidemic has disproportionately impacted the area. TABLE 1. HIV/AIDS INCIDENCE AND PREVALENCE IN THE SATGA/HSDA, 2012-2014 AIDS INCIDENCE HIV INCIDENCE AIDS PREVALANCE HIV PREVALANCE TOTAL 2012 2013 2014 2012 2013 2014 2012 2013 2014 2012 2013 2014 2012 2013 2014 168 165 142 334 392 347 3049 3145 3186 2225 2463 2628 5776 6165 6303 As of December 31, 2014, there were 2,628 PLWH in the SATGA/HSDA. Males represent 85% of incidence while females represent 15%. The Hispanic PLWH represent 56%; 23% are White; and another 17% are Black, less than 1% reported as “Other” which include Asian, Pacific Islander, Native American, and 3% did not report race or ethnicity. The largest age group for PLWH is 25-34, who make up 29%, followed by those 35-44, who make up 23%, and the ‘Aged’ 45+, at 37%. Seventy-one percent (71%) of PLWH reported MSM as the mode of exposure with heterosexual contact being the second highest category at 16%. As of December 31, 2014, there were 3,186 persons living with AIDS (PLWA) in the SATGA/HSDA. Of the cases reported, Hispanics comprise 61% of the AIDS prevalence, while White represents 22%, “others” are less than 1%, and PLWA not reporting race or ethnicity are 3%. Blacks comprise 13% of AIDS prevalence. PLWA tend to be older than PLWH, with 66% aged 45 and older, compared to 37% of HIV cases. Among PLWA diagnosis, a “late tester” is defined as having an AIDS diagnosis that occurred in 12 months of the initial HIV diagnosis. In the SATGA/HSDA, this population is a subset of AIDS cases and is significant to the increasing rates of reported cases. In 2014, 29% of those who tested positive for HIV were diagnosed with AIDS during the year. This pattern is most evident in Bexar County, the largest single population county in the twelve-county San Antonio Region and the county with the highest incidence and prevalence of the disease. Number of new AIDS cases reported in the past three years (2012 – 2014): There were 475 new AIDS diagnoses reported in the SATGA/HSDA between January 1, 2012 and December 31, 2014, including 168 new cases in 2012, 165 new cases in 2013, and 142 new cases in 2014. Among new AIDS cases reported January 1, 2012 through December 31, 2014, 83% were male and 17% were female; 61% Hispanic, 19% White, 11% Black and less than 1% “Other.” The largest age group was the ‘Aged’ who are 45+ years of age, with 37% of new AIDS cases. Individuals between the ages of 35-44, represent 22% of new AIDS cases. Individuals 25-34 years of age comprise 29%. MSM continue to represent the largest exposure category among new AIDS diagnoses with 67%, followed by heterosexual 15%, Intravenous Drug User (IDU) 11% and MSM/IDU 4%. The pediatric exposure group only accounts for less than 1% of new AIDS cases. • Total number of funded CDC programs • Total number of HIV testing sites (CDC/HRSA funded) • Routine testing none since Dec 2014 • Needle exchange programs 8 | P a ge San Antonio TGA/HSDA 2017-2021 Integrated Comprehensive HIV/AIDS Services Plan b. Epidemiologic Overview This overview presents information on known cases of HIV infection in the SATGA/HSDA diagnosed through December 31, 2014 and reported as of June 30, 2015. The number of PLWH in Texas has increased because highly effective treatment has lengthened their lives – people with HIV who get early treatment (and stay on treatment) have lifespans nearly comparable with people without HIV. New diagnoses of HIV infection, on the other hand, have been stable. As in the State, over the past five years, the number of SATGA residents living with diagnosed HIV infections has increased by about 5% a year, rising from about 4,700 in 2010 to more than 5,800 in 2014. In contrast to State trends, the number of new diagnoses in the SATGA also increased by about 8% over the past five years, although TDSHS estimates that the number of new infections in the area did not increase significantly. 600 8,000 PLWH up 5% each year 500 5,814 5,598 5,288 6,000 5,105 400 4,738 x 395 V d w 300 350 356 347 4,000 HI Ne 321 h t 200 wi New HIV dx up about 8% g 2,000 n vi 100 Li e pl 0 0 o e 10 11 12 13 14 P Figure 2: SATGA residents living with diagnosed HIV infections and residents with new HIV diagnoses, 2010-2014 Gay and bisexual men and other MSM made up more than two of every three SATGA residents living with diagnosed HIV infections in 2014; for Texas overall, the share for MSM is closer to half. Heterosexuals made up less than one in five PLWH. Hispanics made up the largest race/ethnic group of PLWH – about three in five. More than half the PLWH were 45 or older. MSM have an even larger presence among those newly diagnosed, with MSM making about three in four SATGA residents newly diagnosed from 2010 to 2014. Heterosexuals made up about 13% of the new diagnoses, which is similar to their representation in PLWH, but the count of high risk heterosexual (HRH) diagnoses were flat from 2010 and 2013, as were new diagnoses in IDU and MSM/IDU. The only group to show increases in new diagnoses were MSM. 9 | P a ge San Antonio TGA/HSDA 2017-2021 Integrated Comprehensive HIV/AIDS Services Plan 15-24 MSM Other 6% 68% Hispanic 4% 45+ 59% 53% White 22% 25-34 IDU 19% 10% HRH Black 35-44 16% 15% MSM 22% Other IDU 1% 5% Figure 3: 2014 PLWH in the SATGA by mode of transmission, race/ethnicity, and age Hispanics made up about three in five SATGA residents who were newly diagnosed between 2010 and 2014. The profile of Texans with new diagnoses is younger than the profile of PLWH – about one in three were 15-24 years old at the time of their diagnosis. This trend is driven by increased diagnoses in young MSM. 45+ 35-44 MSM Other 17% 12% 75% 4% Hispanic 64% White 18% 15-24 25-34 32% HRH IDU Black 39% 13% 8% 14% Other MSM 0% IDU 4% Figure 4: SATGA residents newly diagnosed with HIV from 2010-2014 by mode of transmission, race/ethnicity, and age at diagnosis Four groups made up 70% PLWH in 2014 and more than three out of four new diagnoses over the last five years: Black MSM, Hispanic MSM, White MSM, and Black HRH women. Hispanic MSM alone made up around half of the PLWH and persons newly diagnosed with HIV. Please note that Hispanic heterosexual women make up a larger number of PLWH and new diagnoses in this SATGA than in the state overall (about 4% of prevalence and new diagnoses). 10 | P ag e