KINE 3350 - Infographic

2016 Comprehensive HIV/AIDS Needs Assessment

March 2017

Ryan White Planning Council of the Dallas Area 2016 Comprehensive HIV/AIDS Needs Assessment TABLE OF CONTENTS

4/19/2017 - i - New Solutions, Inc.

TABLE OF CONTENTS Page

TABLE OF CONTENTS .......................................................................................................................... i ACKNOWLEDGEMENTS ...................................................................................................................... iv LIST OF ACRONYMS ............................................................................................................................ vi EXECUTIVE SUMMARY ....................................................................................................................... ES-1 1. INTRODUCTION AND METHODOLOGY ................................................................................. 1.1 Introduction ................................................................................................................ 1.1 Methodology ............................................................................................................... 1.2 2. REGIONAL DEMOGRAPHIC PROFILE ..................................................................................... 2.1 Income and Poverty .................................................................................................... 2.3 Race and Ethnicity ....................................................................................................... 2.4 HIV/AIDS Prevalence in the Region ............................................................................. 2.7 Dallas County Demographics and HIV/AIDS Prevalence ............................................. 2.8 3. EPIDEMIOLOGY PROFILE SUMMARY .................................................................................... 3.1 Monitoring the Epidemic ............................................................................................ 3.1 PLWH and New Diagnoses by Gender ........................................................................ 3.5 Disproportionate Impact ............................................................................................. 3.9 Unmet Need ................................................................................................................ 3.14 Sexually Transmitted Diseases .................................................................................... 3.18 HIV Care Continuum .................................................................................................... 3.21 Linkage to Care ............................................................................................................ 3.27 Retention in Care ........................................................................................................ 3.28 Measures of Viral Load................................................................................................ 3.30 Ryan White HIV/AIDS Program Client In-Care Profile ................................................. 3.33 4. CHARACTERISTICS OF THE POPULATION AND PRIORITY POPULATIONS .............................. 4-1 Total Sample In-Care and Out-of-Care ........................................................................ 4-2 Black/African-American Men and Women ................................................................. 4-22 Hispanic/Latino Men and Women .............................................................................. 4-42 Men Who Have Sex With Men (MSM) ........................................................................ 4-62 Transgender Persons ................................................................................................... 4-79 Youth (Age 13-24) ....................................................................................................... 4-95

Ryan White Planning Council of the Dallas Area 2016 Comprehensive HIV/AIDS Needs Assessment TABLE OF CONTENTS

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TABLE OF CONTENTS (CONTINUED)

Page 5. SERVICES CATEGORIES .......................................................................................................... 5-1 CORE SERVICES ............................................................................................................ 5-6 (Outpatient) Ambulatory Medical Care ................................................................ 5-7 AIDS Drug Assistance Program & AIDS Pharmaceutical Assistance (Local) .......... 5-28 Early Intervention Services ................................................................................... 5-36 Health Insurance Premium & Cost Sharing Assistance for Low Income Individuals .................................................................................... 5-40 Home Health Care ................................................................................................ 5-46 Home and Community-Based Health Services – Home Aides and Assistants ...... 5-49 Hospice Services ................................................................................................... 5-54 Medical Case Management, including Treatment Adherence Services ............... 5-57 Medical Nutrition Therapy ................................................................................... 5-63 Mental Health Services ......................................................................................... 5-68 Oral Health Care ................................................................................................... 5-74 Substance Abuse Outpatient Care ........................................................................ 5-79 SUPPORT SERVICES ..................................................................................................... 5-86 Child Care Services ................................................................................................ 5-87 Emergency Financial Assistance ........................................................................... 5-91 Food Bank/Home Delivered Meals ....................................................................... 5-96 Health Education/Risk Reduction ......................................................................... 5-101 Housing ................................................................................................................. 5-111 Linguistic Services ................................................................................................. 5-126 Medical Transportation ........................................................................................ 5-131 Non-Medical Case Management .......................................................................... 5-138 Other Professional Services (including Legal Services and Permanency Planning) ..................................................................................... 5-143 Outreach Services ................................................................................................. 5-151 Psychosocial Support Services .............................................................................. 5-157 Referral for Health Care Support Services ............................................................ 5-162 Rehabilitation Services ......................................................................................... 5-166 Respite Care .......................................................................................................... 5-170 Substance Abuse Services (Residential) ............................................................... 5-178 6. PROVIDER CAPACITY AND CAPABILITY ................................................................................. 6-1 Provider Overview ....................................................................................................... 6-1 Service Capacity .......................................................................................................... 6-1 System-wide Change to Improve Services for PLWH .................................................. 6-3 Barriers to Care ........................................................................................................... 6-3

Ryan White Planning Council of the Dallas Area 2016 Comprehensive HIV/AIDS Needs Assessment TABLE OF CONTENTS

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TABLE OF CONTENTS (CONTINUED)

Page 7. FOCUS GROUP AND KEY INFORMANT INTERVIEW DISCUSSIONS ........................................ 7-1 Enrollment Process ..................................................................................................... 7-1 Health Information Exchange Infrastructure/Improve Case Coordination/ARIES ...... 7-3 PrEP ............................................................................................................................. 7-4 Physiological Needs ..................................................................................................... 7-4 Funding ........................................................................................................................ 7-5 Recommendations ...................................................................................................... 7-6 LIST OF APPENDICES 1.1 Consumer Survey – English and Spanish Versions ............................................................. APP-1 1.2 Focus Group Guide............................................................................................................. APP-42 1.3 Key Informant Interview Guide .......................................................................................... APP-44 1.4 Provider Capacity Survey ................................................................................................... APP-45 2.1 Dallas Area Zip Codes ......................................................................................................... APP-50 3.1 Fact Sheets Compiled by TSDHA, with Additional Graphical Displays ............................... APP-51

Ryan White Planning Council of the Dallas Area 2016 Comprehensive HIV/AIDS Needs Assessment ACKNOWLEDGEMENTS

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ACKNOWLEDGEMENTS Planning Council Members

 Auntjuan Wiley

 Bruce B. Douglas

 Bryant Porter

 Cipriano Gomez III

 Darius Ahmadi

 Del Wilson

 Gary Benecke

 John Dornheim

 Karin Petties

 Kirk Myers

 Leonardo Zea

 Lionel Hillard, Vice Chair

 Louvenia Freeman

 Lori Davidson

 Helen Turner Goldenberg, Chair

 Jonathan Thorne

 Nikita Carlene Toppin Dera

 Merra Rao-Bette

 Phillip Scheldt

 Reymundo E. Anthony

 Robert Baxter

 Robert Lynn

 Robert McGee II

 Sonny Muniz-Blake, Vice Chair

 Stacie McNulty

 Tom Emanuele

 Yolanda Jones

Planning & Priorities Committee

 John Dornheim

 Lori Davidson

 Nikita Carlene Toppin Dera

 Robert Lynn

 Robert L. McGee II

 Sonny Muniz-Blake, Vice Chair

 Stacie McNulty, Chair

 Woldu Ameneshoa

Consumer Council Committee

 Auntjuan Wiley, Chair

 Cipriano Gomez III

 Donna Wilson

 Helen Turner Goldenberg, Vice Chair

 John Dornheim

 Karin Petties

 Linda Freeman

 Lionel Hillard

 Meera Rao-Bette

 Ricky Tyler

 Robert L. McGee II Needs Assessment Work Group

 Sonny Muniz-Blake

 John Dornheim

 Lori Davidson

 Joycelyn Caesar

 Robert L. McGee II

 Stacie McNulty

 Woldu Ameneshoa

 Auntjuan Wiley

 Helen Turner Goldenberg

 Ricky Tyler

 Donna Wilson

 Karin Petties

 Linda Freeman

 Lionel Hillard

 Robert McGee II

 Meera Rao-Bette

 Dale McEowen

 Jetta Plotke

 Norma Piel-Brown

 Kellie Norcott

 Abigail Erickson

 Marilyn Quinones

 Steven Pace

 Edgar Carmona

 Skylar Lange

 Joni Wysocki

 Gary Benecke

 Chris Howell

 Brent Pimentel

 Louis Henry

 Jonathan Thorne

 Phillip Scheldt

 Leonardo Zea

 Andrew Wilson

 Annie Sawyer- Williams

 Justin M. Henry

 Lynette Smith-Clay

 Sonia Contreras

 Angela Jones

 Glenda Blackmon- Johnson

 Thomas Reed

Ryan White Planning Council of the Dallas Area 2016 Comprehensive HIV/AIDS Needs Assessment ACKNOWLEDGEMENTS

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Ryan White Funded Providers

 AIDS Interfaith Network

 AIDS Services of Dallas

 Bryan’s House

 Callie Clinic

 Dallas County Health Division

 Dallas County Hospital District – Parkland

 Health Services of North Texas

 Prism Health of North Texas (Formerly AIDS Arms)

 Resource Center of Dallas

Additional Agencies and Individuals

 Abounding Prosperity, Inc.

 AIDS Healthcare Foundation

 AIDS Walk South Dallas

 Avita Pharmacy

 The Afiya Center

 Homeward Bound, Inc.

 The Bridge Homeless Recovery Center

 The Council on Alcohol and Drug Abuse

 UT Southwestern School of Health Professions Department of Health Care Sciences - The Community Prevention and Intervention Unit

 Office of Steven M. Pounders, M.D., Internal Medicine

 Pride Pharmacy

 Texas Department of State Health Services – Epidemiology and

Supplemental Projects Group

 The Salvation Army DFW

 Uptown Physicians Group

 Candace Moore – Parkland - LGBT Services/HIV Prevention

 Ocie Menefield – Resource Center - United Black Ellument

Ryan White Planning Council of the Dallas Area 2016 Comprehensive HIV/AIDS Needs Assessment ACRONYMS

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ACRONYMS AA Administrative Agency ACA Affordable Care Act ADAP AIDS Drug Assistance Program AETC AIDS Education and Training Center AIDS Acquired Immunodeficiency Syndrome ARIES AIDS Regional Information and Evaluation System CBO Community-Based Organization CDC Centers for Disease Control CHIP Children’s Health Insurance Program DPA Dallas Planning Area DSHS Texas Department of State Health Services EFA Emergency Financial Assistance eHARS Enhanced HIV AIDS Reporting System EIIHA Early Intervention of Individuals with HIV/AIDS EIS Early Intervention Services EMA Eligible Metropolitan Area FPL Federal Poverty Level HAB HIV/AIDS Bureau HCC HIV/AIDS Care Continuum HERR Health Education Risk Reduction HHS Health and Human Services HIV Human Immunodeficiency Virus HOPWA Housing Opportunities for Persons Living With HIV/AIDS HRSA Health Resources and Services Administration HSDA HIV Service Delivery Area IDU Injecting Drug Use(r) LPAP Local Pharmaceutical Assistance Program MSM Men who have Sex with Men NMCM Non-Medical Case Management Services NSI New Solutions, Inc. OAMC (Outpatient) Ambulatory Medical Care PDSA Plan-Do-Study-Act PLWH Person(s) Living with HIV or AIDS P&P Planning and Priorities PrEP Pre-Exposure Prophylaxis RWHAP Ryan White HIV/AIDS Program RWPC Ryan White Planning Council of the Dallas Area STAR (ARIES) Statistical Analysis Report

Ryan White Planning Council of the Dallas Area 2016 Comprehensive HIV/AIDS Needs Assessment EXECUTIVE SUMMARY

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EXECUTIVE SUMMARY INTRODUCTION The Ryan White Planning Council of the Dallas Area (RWPC) is responsible for planning activities to support the use of Human Immunodeficiency Virus (HIV) medical care among people living with HIV/AIDS (PLWH) in a 12-county region. While a full continuum of services is available through Ryan White HIV/AIDS Program (RWHAP) funded programs and community linkages, understanding the needs of PLWH allows the RWPC to effectively plan improvements in access, barrier reductions, service quality and satisfaction enhancements, and linkage to care for persons who know their status and are not receiving medical care. Funding allocations follow effective planning, and this comprehensive needs assessment is designed to provide essential information for that decision-making. Specific objectives include:

 Identify status and trends in the HIV/AIDS epidemic within the Dallas EMA/HSDA and Sherman Denison HSDA, focusing on recent changes and emerging affected populations;

 Evaluate the system for and rate of linking PLWH into medical care;

 Construct the HIV Care Continuum depicting the progression from HIV diagnosis to viral load suppression;

 Identify consumer service needs, needs that are not currently being fulfilled, utilization patterns, and barriers to care;

 Obtain detailed information on PLWH with unmet need for medical care, including demographics, barriers, and strategies to connect to care;

 Identify and evaluate the system of HIV/AIDS care, evaluating current capacity, gaps, and barriers (including, but not limited to eligibility barriers) in the continuum and treatment cascade. This will include both HIV/AIDS service providers and providers of services that PLWH use.

 Provide depth insights into five priority populations: Black/African-Americans, Hispanic/Latinos, MSM, Youth and Transgender.

To accomplish these objectives, the following activities were undertaken:

1. Surveillance and sociodemographic data about the population of the region and status of the epidemic obtained from the Texas Department of State Health Services (DSHS) and the U.S. Census;

2. A detailed survey of 697 PLWH of which 457 were in-care and 240 were out-of-care/returned to care;1

3. Four in-depth focus groups conducted with: Direct Personnel, Planning Council Members/Staff, Providers, and Consumers conducted with supplemental interviews were for each focus group to ensure adequate feedback;

1 Consumers meeting one of the following criteria were considered Out-of-Care: (1) Not currently receiving HIV

medical care, with at least 12 months since the last medical appointment. This is the HRSA definition of “out-of- care” which is “no HIV medical care, no viral load or CD4 counts and no antiretroviral medications in the last 12 months.” These people may or may not be receiving other RWHAP or HIV services. (2) Diagnosed between 2013 and 2016 that failed to link to care within six months of diagnosis. They may currently be in care. (3) Diagnosed between 2013 and 2016, linked to care after diagnosis but dropped out-of-care for at least six months. They may now be back in care. (4) Dropped out-of-care for at least 12 months but are now back in care. They should have been back in care for no more than two years.

Ryan White Planning Council of the Dallas Area 2016 Comprehensive HIV/AIDS Needs Assessment EXECUTIVE SUMMARY

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4. A survey of 13 RWHAP providers including a detailed profile of provider capacity with questions regarding the impact of healthcare reform along with an inventory of funded and non-funded RWHAP local providers offering services that could expand the RWPC defined continuum of care (HCC);

5. Key informant interviews with community leaders, healthcare leaders, and RWHAP providers. PERSPECTIVES ON THE NATIONAL EPIDEMIC The CDC reports 1.2 million people in the United States living with HIV, with approximately 400,000 newly diagnosed infections annually.2 In the past decade, rates of new infection have decreased 19%; however, certain at-risk populations such as men having sex with men (MSM) and African Americans as well as certain geographies, including the South, have not seen such declines. Although MSM comprise just two percent of the U.S. population, they accounted for two-thirds of all persons diagnosed with HIV in 2014. In the last decade, MSM diagnosis increased six percent with greater increases found among Blacks and Latinos. According the Kaiser Family Foundation, in 2015, ten states including Texas accounted for approximately two-thirds (65%) of HIV diagnoses among adults and adolescents nationwide. Texas had the third highest number of new diagnoses nationwide accounting for 11% of HIV incidence. When controlling for population variability, Texas ranked seventh with 20.1 new HIV diagnoses per 100,000 residents, 37% higher than the national rate.3 As a positive development, however, some states including Texas have succeeded in reducing the number of new diagnosis. According to the CDC, new infections in Texas declined 2.4% in 2014 along with seven other states.4 Prevention, testing and timely linkage to care for newly or previously diagnosed individuals are routinely cited as the most effective way to reduce or eliminate the epidemic. Ending the HIV/AIDS epidemic in the United States has been proclaimed within reach by the National Institute of Allergy and Infectious Diseases. In 2016, HRSA required all RWHAP jurisdictions to develop plans to integrate prevention and care with the ultimate goal of reducing new infections, optimizing linkage and retention in care and achieving sustained viral load suppression. With this as a backdrop, this needs assessment provides the baseline of information to direct provision of services for PLWH in the Dallas Planning Area. DEMOGRAPHIC AND EPIDEMIOLOGICAL PROFILE There are 12 counties in the Dallas and Sherman-Denison HSDAs, with a total estimated population of 5,033,408 in 2015. Considering the demographics in this region:

 Dallas County is the largest with 2,553,385 persons, followed by Collin County with a total population of 914,127 and Denton with 780,612 in 2015.

 The remaining counties range in population from 163,000 to 33,700 persons.

 Between 2015 and 2015, population in the region grew by 11%.

2 https://www.cdc.gov/nchhstp/newsroom/docs/factsheets/hiv-data-trends-fact-sheet-508.pdf 3 http://kff.org/hivaids/fact-sheet/the-hivaids-epidemic-in-the-united-states-the-basics/ 4 https://twitter.com/CDC_HIVAIDS

Ryan White Planning Council of the Dallas Area 2016 Comprehensive HIV/AIDS Needs Assessment EXECUTIVE SUMMARY

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 The farther north in the region, the larger the percentage of Whites/Caucasians. This ranges from 79.7% in Fannin (Sherman-Dennison HSDA) to 31.5% in Dallas.

 Blacks/African-Americans range from 21.8% in Dallas to 2.4% in Cooke (Sherman-Denison).

 The highest concentration of Hispanic/Latinos reside in the counties of Dallas (39.0%), Ellis (24.7%), and Navarro (25.2%).

 The counties with the lowest per capita incomes tend to have the highest percentage of families living below poverty; these include Dallas, Hunt, Henderson, and Navarro.

 There are six zip codes within the city of Dallas which, when combined, contain over 25% of PLWH in the region.

Data for this epidemiological profile were obtained from the Texas Department of State Health Services (DSHS) reflecting the number of PLWH in the Dallas Eligible Metropolitan Area (EMA), Dallas HIV Service Delivery Area (HSDA), and the Sherman-Denison HSDA5. Key findings:

 Prevalence increased. In 2015, 19,793 people were known to be living with HIV/AIDS in the Dallas EMA, 19,768 in the Dallas HSDA, and 226 in the Sherman-Denison HSDA. Between 2011 and 2015, the epidemic grew by 20% in the Dallas EMA, 17% in the Dallas HSDA, and 28% in Sherman- Denison. Prevalence rates increased by 15% in the Dallas EMA, 17% in the Dallas HSDA and 25% in the Sherman-Dennison HSDA.

5 The data do not include those unaware of their HIV infection or those who tested HIV-positive solely through an anonymous HIV test.

Ryan White Planning Council of the Dallas Area 2016 Comprehensive HIV/AIDS Needs Assessment EXECUTIVE SUMMARY

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 Incidence has varied. In the last five years, the highest number of new diagnoses in the Dallas EMA occurred in 2011, with 1,648 people diagnosed with HIV or AIDS. Incidence declined in the Dallas EMA through the five-year period.

 Mortality has declined. Mortality statistics lag behind incidence reporting and are released only through 2013. From 2009 through 2013, mortality among PLWH in the Dallas EMA declined 6% with variation during this period. The largest decline in mortality (20%) occurred in the Dallas EMA from 2011 to 2012. Statistics for the Sherman-Denison HSDA were normally less than five and more variable due to the small population size.

 HIV and AIDS cases. The increase in the overall epidemic also contributed to general increases in the number and rate of both HIV and AIDS cases. In the Dallas EMA, the proportion of PLWH with an AIDS diagnosis in 2011 was 54%. By 2015, this percentage declined slightly to 52%, indicating that individuals could have been diagnosed earlier in their disease stage.

 Epicenter has not moved. Dallas County continues to be the epicenter of the regional epidemic with 82% of PLWH residing there.

 Higher unmet need among PLWH-not AIDS. When compared to PLWH with AIDS, unmet need by disease status finds PLWH with HIV with higher unmet need in all population categories. The exceptions are Hispanics, those individuals 45 years or older, as well as the IDU and MSM/IDU transmission categories.

 HIV Continuum of Care (HCC). The 2015 Continuum of Care (HCC) provides salient performance indicators of linkage, retention and suppression comparing all PLWH. Across all regions of the DPA, results were consistent, reported on average 79% linkage to care with at least one medical visit or lab test, 72% retention with two or more medical visits and 63% viral suppression. Similar results were reported by gender, race/ethnicity, age and transmission mode.

 Linkage to Care. On average, 64% of PLWH in the Dallas EMA or HSDA were linked to care within one month of diagnosis in 2015. Sherman-Denison HSDA reported 87% linked to care.

 Retention in Care. In the Dallas EMA and HSDA, 72% of PLWH who were linked to care in 2015 were retained in care. The Dallas HSDA had the lowest percentage retained in care (69%).

 Measures of Viral Load. Viral load measures were calculated to examine the extent to which in- care and monitored PLWH achieve viral suppression when compared to those in various populations. In the Dallas EMA general population, the population of Aware and Unaware PLWH (Population Viral Load) are approximately 52% virally suppressed. Of those who are Aware but perhaps not always in care (Community Viral Load), 63% were virally suppressed in 2015. Of those in care and receiving at least two medical visits or lab tests (Monitored Viral Load), approximately 82% were virally suppressed.

 RWHAP Client In-Care Profile. In 2016, 9,609 received RWHAP services of whom 1,427 were new to the program. Gender, race/ethnicity, age and transmission mode were largely reflective of the epidemic.

Ryan White Planning Council of the Dallas Area 2016 Comprehensive HIV/AIDS Needs Assessment EXECUTIVE SUMMARY

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CHARACTERISTICS OF THE POPULATION AND PRIORITY POPULATIONS Combining data from all primary and secondary research study components (epi-profile, demographic profile, key informant interviews, focus groups, and consumer surveys), this section analyzes survey results of the total sample of in-care and out-of-care consumers. Five priority populations for the Comprehensive Needs Assessment were selected by the Planning & Priorities Committee: Black/African- American, Hispanic/Latino, MSM, Transgender Individuals and Youth Age 13-24. The consumer survey sample was comprised of 697 PLWH that included 457 (66%) in-care consumers and 240 (34%) out-of-care/returned to care. Survey respondents conformed to the overall epidemic in the areas of gender and age: 75% were male respondents, 23% female, and 2% Transgender. The age profile of respondents was slightly older than those reflected in the regional epidemic. By race, Whites/Caucasians and Hispanics were under-sampled on the consumer survey relative to their presence in the regional epidemic, and Black/African-Americans were over-sampled. Eighty-three percent of the survey sample resided in Dallas County, which is comparable to the Dallas County percentage in the regional epidemic (82%). The consumer survey allowed the selection of multiple transmission modes. The most frequently identified were men having sex with men (50%), heterosexual contact (32%), IDU (6%), and Other (9%). Table ES.1 provides an overview of the survey questions and responses by the total sample and the five priority populations. Highlighted statistics from the priority populations are notable. The results represent a population that is predominantly male, infected either by MSM or heterosexual contact, poorly educated, unemployed, and with low income. Two-thirds were in-care, the remainder either out- of-care or returned to care after a period of no care. Respondents identified various barriers to staying in care including keeping appointments, transportation, substance abuse involvement and “not feeling sick.”

19,793 15,664 14,281 12,533

100% 79% 7… 63%

0% 20% 40% 60% 80% 100%

0

5,000

10,000

15,000

20,000

HIV+ Individuals Living, 2015

At least one visit/lab

Retained In Care Achieved Viral Suppression

HIV Care Continuum Dallas EMA

2015

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Table ES.1 Consumer Survey Summary Results

Total Sample

Total Sample (n=697)

Black/African- American (n=387)

Hispanic/Latino (n=113)

MSM (n=349)

Transgender (n=15)****

Youth (n=22)****

Gender***

Male 75.0% 71.3% 73.5% - - 68.2%

Female 22.8% 27.1% 20.4% - - 22.7%

Other Gender Identity 2.2% 1.6% 6.2% - - 9.1%

Transmission Mode*

MSM 50.1% 43.2% 49.6% 100.0% 0.0% 63.6%

IDU 6.0% 5.4% 6.2% 0.0% 13.3% 0.0%

MSM+IDU 2.4% 0.8% 3.5% 4.9% 0.0% 4.5%

Heterosexual Contact 31.9% 40.8% 26.5% 1.1% 0.0% 9.1%

Do not know 7.9% 7.0% 9.7% 2.0% 6.7% 4.5%

Other 9.6% 8.3% 12.4% 2.3% 80.0% 22.7%

Educational Attainment*

Eighth Grade or Less 3.3% 3.4% 4.4% 1.4% 0.0% 0.0%

Some High School 12.9% 12.9% 19.5% 8.0% 13.3% 22.7%

High School Graduate/GED 34.9% 41.1% 33.6% 31.5% 33.3% 36.4%

Technical or Trade School 4.9% 4.4% 2.7% 5.2% 0.0% 0.0%

Some College 28.8% 26.6% 24.8% 35.8% 26.7% 40.9%

Completed College 10.3% 7.5% 12.4% 12.6% 26.7% 0.0%

Graduate Education 5.0% 3.9% 0.0% 4.6% 0.0% 0.0%

Other 0.9% 0.3% 2.7% 0.9% 0.0% 0.0%

Military Service**

Yes 5.9% 6.2% 4.4% 4.6% 13.3% 0.0%

No 93.5% 93.5% 94.7% 95.1% 86.7% 100.0%

Employment Status

Work Full-Time 13.3% 11.4% 20.4% 14.9% 20.0% 18.2%

Work Part-Time 11.0% 9.6% 12.4% 12.0% 6.7% 18.2%

Not Working 75.6% 79.1% 67.3% 73.1% 73.3% 63.6%

Unemployed Status**

I am looking for a job 23.0% 21.9% 27.6% 27.5% 27.3% 42.9%

My health keeps me from working - I am not on disability 14.8% 16.3% 14.5% 12.2% 9.1% 0.0%

My health keeps me from working - I am on disability 44.8% 46.4% 36.8% 45.1% 45.5% 14.3%

Income**

Less than $950 68.1% 74.2% 61.9% 62.5% 73.7% 77.3%

$950-$1,900 22.5% 18.1% 31.9% 24.6% 26.7% 9.1%

Substance Use**

Yes 56.2% 55.3% 51.3% 63.0% 26.7% 77.3%

IV Drug Use - Injected in the Last 2 months**

Yes 3.3% 2.6% 3.5% 4.3% 0.0% 4.5%

Substances Used in Last 6 Months**

Alcohol 69.1% 72.4% 74.1% 74.1% 50.0% 70.6%

Marijuana 46.4% 51.9% 37.9% 48.5% 75.0% 82.4%

Ryan White Planning Council of the Dallas Area 2016 Comprehensive HIV/AIDS Needs Assessment EXECUTIVE SUMMARY

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Total Sample (n=697)

Black/African- American (n=387)

Hispanic/Latino (n=113)

MSM (n=349)

Transgender (n=15)****

Youth (n=22)****

Opioids and Morphine 11.2% 8.4% 10.3% 9.5% 0.0% 17.6%

Stimulants 19.9% 13.1% 24.1% 23.2% 25.0% 23.5%

Drink Alcohol More Than 3 Times a Week

Yes 29.2% 29.0% 34.9% 34.4% 100.0% 58.3%

No 70.8% 71.0% 65.1% 65.6% 0.0% 41.7%

Considering Treatment**

Yes 28.4% 28.3% 30.4% 27.7% 0.0% 17.6%

Depression Diagnosis**

Yes 29.7% 24.8% 24.8% 28.7% 26.7% 9.1%

Received Care After Diagnosis**

After more than 6 months 28.8% 29.5% 28.3% 32.1% 13.3% 9.1%

I have not received HIV medical care 3.7% 5.9% 0.9% 4.0% 13.3% 27.3%

Incarceration**

Yes 12.5% 12.2% 11.5% 12.3% 6.7% 13.6%

HIV Care While Incarcerated**

Yes 80.5% 76.6% 92.3% 72.1% 100.0% 66.7%

HIV Care After Incarceration**

Afraid to tell others I am HIV+ 20.7% 23.4% 30.8% 14.0% 0.0% 66.7%

Could not find a place to live 13.8% 12.8% 23.1% 18.6% 0.0% 66.7%

Did not know where to go for medical care 12.6% 17.0% 23.1% 18.6% 0.0% 33.3%

HIV Medical Care Potential Problems** (in-care only)

Amount of time it takes at the clinic 15.1% 17.0% 14.5% 17.1% 20.0% 0.0%

Paperwork needed 12.9% 13.8% 10.5% 14.4% 20.0% 14.3%

I do not have transportation so it's hard to get there 12.0% 12.6% 10.5% 13.9% 0.0% 14.3%

HIV Medical Care Potential Problems** (out-of-care only)

Amount of time it takes at the clinic 20.8% 20.1% 29.7% 22.6% 40.0% 20.0%

Paperwork needed 20.4% 21.6% 18.9% 18.0% 40.0% 26.7%

I do not have transportation so it's hard to get there 15.8% 15.7% 18.9% 16.5% 0.0% 6.7%

Not Getting HIV Medical Care** (out-of-care only)

I do not feel sick 59.6% 52.6% 1.8% 35.1% 60.0% 10.5%

I do not want to think about being HIV+ 29.8% 24.6% 1.8% 15.8% 20.0% 7.0%

I do not want to take medicines 28.1% 24.6% 0.0% 7.0% 0.0% 3.5%

Dropping Out-of-Care** (out-of-care only)

It was hard to keep appointments 32.3% 38.6% 34.6% 28.4% 33.3% 50.0%

I was using drugs 28.1% 33.0% 19.2% 29.5% 0.0% 33.3%

I did not feel sick 26.9% 31.8% 19.2% 27.4% 66.7% 83.3%

Service Needs**

Dental visits 57.8% 57.4% 65.5% 59.3% 33.3% 63.6%

Food Bank 47.9% 45.7% 48.7% 48.1% 46.7% 27.3%

HIV outpatient medical care 46.9% 50.1% 38.1% 43.3% 53.3% 18.2%

*Respondents could choose more than one answer.

**Select responses are represented; therefore, percentages do not sum to 100%

***Totals may not sum to 100% due to rounding.

****Transgender (n=15, in-care=10, out-of-care=5) and Youth (n=22, in-care=7, out-of-care=15) contain small sample sizes and do not allow for generalization.

Ryan White Planning Council of the Dallas Area 2016 Comprehensive HIV/AIDS Needs Assessment EXECUTIVE SUMMARY

4/19/2017 ES-8 New Solutions, Inc.

Priority Populations African-Americans The consumer survey sample was completed by 387 Black/African-Americans6 living with HIV/AIDS, comprising 56% of the total sample. The Black/African-American men included 253 (55%) in-care and 134 (56%) out-of-care consumers. Characteristics of this population more closely mirrored those of the total sample than the other four.

 Black/African-Americans in the Dallas EMA had the highest infection rate in the region; 1,036.3/100,000 in 2015.

 In 2015, the rate of new infections exceeded more than three times that of Whites/Caucasians and more than three times that of Hispanics.

 Black/African-American MSM had the highest unmet need (24%) when compared with White/Caucasian and Hispanic MSM (17% and 23%, respectively). Findings were similar for MSM/IDU, with 23% of Black/African-Americans having unmet need and 22% of Hispanic MSM with unmet need compared to 16% of White/Caucasians.

 Unmet need among those with heterosexual contact transmission found Black/African-American men with second highest unmet need (29%). Unmet need among Hispanics with heterosexual contact transmission had the highest unmet need (32%).

 Fifty-seven Black/African-Americans who were out-of-care during the last 12 months were asked to provide reasons for not being in care. The most common reasons for not being in care were; “I did not feel sick” (53%), “I do not want to think about being HIV+” (25%), and “I do not want to take medicines”, which tied for second (25%).

 Black/African-Americans mirrored the overall sample in terms of service needs, making general recommendations applicable. However, there appears to be a greater need for case management and counseling services to deal with social determinants and support needs of this population.

Key informants provided the bulk of information regarding needs of priority populations. With respect to Black/African-Americans, the general view was that culturally relevant and appropriate services were important to keeping people in care – “Ask them who do you have sex with,” rather than “Are you gay, straight, etc.?” It is noted that the comments presented below represent the beliefs, opinions and experiences of those interviewed.

Recommendations

1. Require annual cultural competence training to all staff receiving RWHAP funding. 2. Encourage medical and case management personnel to obtain training in identification of

victims of domestic violence and intimate partner violence. 3. Require agencies receiving RWHAP funding to ensure their staffs are culturally and

linguistically representative of the consumers they serve. 4. Support efforts to break down the stigma of HIV among Black/African-Americans and that

normalize testing, Pre-exposure Prophylaxis (PrEP) and healthy behaviors.

6 The consumer survey included a racial option of “Black or Black/African-American,” so this discussion includes consumers who self-designate as either “Black or Black/African-American.”

Ryan White Planning Council of the Dallas Area 2016 Comprehensive HIV/AIDS Needs Assessment EXECUTIVE SUMMARY

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Hispanic/Latinos The consumer survey sample consisted of 113 Hispanic/Latinos7 living with HIV/AIDS, comprising 16% of the total sample. The Hispanic/Latino sample included 76 (67%) in-care consumers and 37 (33%) out-of- care consumers.

 This population is characterized by the highest increase in PLWH in the Dallas EMA from 2011- 2015 of 34.8%.

 Hispanics/Latinos in the Dallas EMA had Hispanics/Latinos had the second highest DSHS unmet need in the Dallas EMA (23%).

 Considering transmission mode as self-reported in the consumer survey, 50% of Hispanics/Latinos were MSM, 27% heterosexual contact, and 6% IDU. Hispanic respondents reported “unknown” or “other” mode of transmission to a greater degree than found in the total survey, 22% vs. 18%.

Key informants spoke of the issues surrounding the undocumented status of some Hispanic/Latino consumers and the need to focus on the family dynamics.

Recommendations

1. Ensure that RWHAP providers maintain adequate numbers of bilingual direct care staff, and that all staff receive annual in-service training in cultural competence.

2. Ensure that continued education and outreach is made in Hispanic/Latino communities to reach those at high risk.

3. Encourage collaboration with CBOs that serve large numbers of Hispanic/Latino clients in outreach efforts with this community.

Men who have Sex with Men (MSM) The consumer survey included 349 men who identify having sex with men (MSM) as their mode of HIV transmission. This is 50% of all consumer survey responses. A similar percentage of MSM were out-of- care as compared to the overall survey sample. Specifically, 38% of MSM were out-of-care compared to 34% of all respondents.

 MSM were predominantly Black, African-American as reflected in the total sample as well. White/Caucasian, Hispanic/Latino and Multi-Race comprised approximately the same proportion collectively as Black/African-American MSM.

 When asked about recent substance use, most frequent substance used among MSM was alcohol (74%) followed by marijuana (49%) and stimulants (23%). In nearly every case, MSM usage was proportionately greater than the total sample.

 Fifty-seven MSM who were out-of-care during the last 12 months were asked to provide reasons for not being in care. The most common reasons for not being in care were: “I did not feel sick”, “I do not want to think about being HIV+”, “I do not have money to pay”, “It is hard to get there (transportation)”.

7 The consumer survey included an ethnicity question asking “Are you Hispanic/Latino?”, so this discussion includes consumers who self-designate as either “Hispanic or Latino.”

Ryan White Planning Council of the Dallas Area 2016 Comprehensive HIV/AIDS Needs Assessment EXECUTIVE SUMMARY

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Recommendations

1. MSMs in the Dallas Planning Area can be stratified by age, race/ethnicity, etc. Priority

populations include African-American MSMs, Hispanic MSMs, and young MSMs. Each group displays some differences by their culture.

a. Targeted approaches should be developed for each subpopulation cited above. b. Provider collaboration will be necessary to expand targeted approaches to various

populations and to share best practices. c. Support providers who successfully use cultural competency training, peer support,

and patient navigation to enhance their success in linking and maintaining PLWH in care.

2. Ensure that all providers employ direct care personnel who reflect the characteristics of the target population.

Transgender Persons The consumer survey sample consisted of 15 Transgender persons living with HIV/AIDS, comprising 2% of the survey sample. The Transgender sample included ten (77%) in-care consumers and five (33%) out-of- care consumers. The size and characteristics of Transgender PLWH are largely undetermined from available data. Because the sample size does not allow for generalizations about this population, the data are presented for informational purposes only.

 Considering transmission mode as identified on the consumer survey, 67% of Transgender reported having sex with a man, 13% reported having sex with a transman, transwoman, transperson or gender nonconforming person transmission, and 13% reported IDU.

 The most frequent substance used in the last six months by Transgender respondents was marijuana (75%) followed by alcohol (50%) and depressants (50%). The latter was significantly higher than found in the total sample.

 Fifty-seven consumers who were out-of-care for the last 12 months were asked to provide their reasons for not getting care. Respondents were given a list of reasons and an opportunity to provide additional reasons for being out-of-care. Responses included: 60% stated they didn’t feel sick, 40% said, “I am afraid of being seen at the clinic”, and “I do not have money to pay.”

Recommendations

1. Increase support for physicians who treat Transgender patients, with priority to those

with HIV or infectious disease experience. Work with the AETC to provide physician education on the care of HIV+ Transgender individuals.

2. Support provider collaboration with Transgender advocates to educate medical, dental, mental health, and substance abuse providers about the service needs of the Transgender community.

3. Work with HRSA, AETC and/or Transgender advocates to develop a program on cultural sensitivity for Dallas area service providers.

4. Encourage providers to develop innovative ways to reach, counsel, test, and link Transgender consumers to available services.

Ryan White Planning Council of the Dallas Area 2016 Comprehensive HIV/AIDS Needs Assessment EXECUTIVE SUMMARY

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Youth (Age 13-24) The consumer survey sample consisted of 22 respondents age 13-24 living with HIV/AIDS, comprising 3% of the survey sample. The youth ages 13-24 sample included seven (32%) in-care and 15 (68%) out-of- care consumers.

 The majority of youth respondents identified as Black/African-American (64%), which is higher than that of the total sample. The percentage of Hispanic youth (23%) was also higher than the total sample (16%). White youth (9%) were underrepresented relative to the total sample (25%).

 Considering transmission mode as identified on the consumer survey, 64% of youths reported having sex with a male, 12% report perinatal transmission, and 9% report heterosexual transmission. MSM transmission is clearly the major transmission mode of this population.

 The majority (77%) of youth survey respondents used drugs or alcohol in the past six months. In contrast to the total sample where alcohol was most frequently cited, the most frequent substance used by youth in the last six months was marijuana (82%), followed by alcohol (71%) and stimulants (24%).

 Nine percent of youth consumer survey respondents were diagnosed with depression, compared to 30% in the total sample. While the small sample size does not allow for conclusion, it is apparent that youth do not receive adequate mental health counseling.

 Fifty-seven youth respondents who were out-of-care during the last 12 months were asked to provide reasons for not being in care. The most common reasons for not being in care were: “I did not feel sick”, “I do not want to think about being HIV+”, “I do not need or want medical care”, “I do not have money to pay” (tied for third).

Recommendations

1. HIV+ youth are difficult to find and even more difficult to link to care. Efforts to engage in

common communication methods, i.e. social media, should be emphasized as an important avenue to pursue.

2. Youth represent the newest priority population in the Dallas Planning Area (DPA). Education and appropriate messaging to this group appear particularly challenging to overcome and should be given strong consideration with respect to follow-up activities.

3. The County Health Department should meet with the local school districts to discuss rates of teen pregnancies, STDs, alcohol and other substance use and HIV among youth as a continuing public health issue, to broaden the school curriculum for health education to include information and tactics on prevention and healthy behaviors. Priority should be placed on schools where high risk behaviors are known to exist.

4. Encourage RWHAP providers to increase their use of popular social media sites, apps (used by teens and young adults) to provide outreach and early intervention services.

5. Enhance prevention and outreach activities by having providers hold events on college campuses and at events where young people are likely to gather. Utilize peer outreach whenever possible.

Ryan White Planning Council of the Dallas Area 2016 Comprehensive HIV/AIDS Needs Assessment EXECUTIVE SUMMARY

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SERVICE ANALYSIS The consumer survey asked the following questions for 35 core and support services:

 Do You Use This Service Now or Over the Past Year?  If a service is being used, it is assumed the service is needed.  If the service is being used, the next question asks about ease of use.  If the service is not being used, the next question asks about need for the service.

 How Easy Was It For You To Get the Service?  The number and percentage of people who use the service and found it easy to get is

presented as Need Met Easily  The number and percentage of people who use the service and found it hard or somewhat

hard to get is presented as Need Met Hard.  Anyone with a service that was hard or somewhat hard to get was asked the reason under

the barriers section.

 Unfulfilled need for a service.  If someone is not using the service but states a need for it, he/she is considered to have

an unfulfilled need for the service.  The number and percentage of people who have an unfulfilled need is presented as Need

Not Met.  Anyone with an unfulfilled need was asked the reason under the barriers section.

 Barriers to Care.  If a service fulfilled the criteria for either Need Met Hard or Somewhat Hard or Need Not

Met, the respondent was asked either, “What is the main reason you were not able to get this service?” or “What is the main reason this service was hard to get?”

 Specific barriers were identified for each service.  A list of “problems” with HIV medical care asked early in the survey replaced the barrier

questions for Ambulatory/Outpatient Medical Care. Detailed results for all service categories are provided in Section 5 of this report. Ten selected service categories are included here as most significant: oral health care, ambulatory outpatient medical care, OB/GYN, specialty medical care, food and nutritional services, medical case management, medical transportation, emergency financial assistance, long term housing and mental health therapy. Oral Health Care Oral Health Care services provide outpatient diagnostic, preventive, and therapeutic services by dental health care professionals, including general dental practitioners, dental specialists, dental hygienists, and licensed dental assistants. Dental care was the highest-ranking service need. It ranked first in total need and first in unfulfilled need. Dental care was widely needed among in-care and out-of-care respondents, being their top identified service need and unfulfilled need. Both in-care and out-of-care survey respondents ranked dental care as the highest unfulfilled need.

Ryan White Planning Council of the Dallas Area 2016 Comprehensive HIV/AIDS Needs Assessment EXECUTIVE SUMMARY

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Table ES.2 Service Category Summary Results – Oral Health Care

Total Sample, In-Care, Out-of-Care

ORAL HEALTH CARE Total Sample

Total In-Care Out-of-Care

Service Need

If used, need met easily 68% 67% 64%

If not used, unfulfilled need 66% 65% 68%

No need 34% 35% 32%

Ranking

Total Need Rank 1 2 1

Unfulfilled Need Rank 1 1 1

Barriers to Care

"Long wait to get an appointment" 32% 34% 29%

"Limited funding" 26% 21% 31%

Considering need for dental services:

 While 68% of consumer survey respondents reported their need for dental care was met easily, 66% reported their need is unfulfilled.

 Despite their small number, 100% of in-care Youth (3) and Transgender individuals (2) reported their needs not met.

 In-care Hispanic/Latino men and women (70%), and in-care Black/African-American men and women (66%) had high rates of unfulfilled needs.

 68% of in-care MSMs also had dental needs not met.

 Oral health care has remained the top priority since 2010, the need and unfulfilled need further increased in 2016.

Ambulatory/Outpatient Medical Care Primary medical care for the treatment of HIV infection includes the provision of care that is consistent with the Public Health Service's guidelines. Such care must include access to antiretroviral and other drug therapies, including prophylaxis and treatment of opportunistic infections and combination antiretroviral therapies.

Table ES.3 Service Category Summary Results – HIV Outpatient Medical Care

Total Sample, In-Care, Out-of-Care

HIV OUTPATIENT MEDICAL CARE Total Sample

Total In-Care Out-of-Care

Service Need

If used, need met easily 77% 79% 70%

If not used, unfulfilled need 34% 28% 40%

No need 66% 72% 60%

Ryan White Planning Council of the Dallas Area 2016 Comprehensive HIV/AIDS Needs Assessment EXECUTIVE SUMMARY

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HIV OUTPATIENT MEDICAL CARE Total Sample

Total In-Care Out-of-Care

Ranking

Total Need Rank 2 1 2

Unfulfilled Need Rank 18 20 12

Barriers to Care

"The amount of time it takes at the clinic" 15% 11% 19%

"Paperwork needed" 13% 12% 15%

 Twenty-three percent reported their need for this service was met with difficulty.

 Thirty-four percent reported an unfulfilled need.

 In-care African-American men and women and in-care MSM had the largest percentages reporting no need for HIV outpatient medical care (excludes populations with small numbers of respondents).

 Among respondents that had not used this service in the past 12 months, out-of-care African American men and women and out-of-care MSM had the highest unmet need (excludes populations with small numbers of respondents).

 In-care Hispanic men and women and in-care MSM had the largest percentage with their need met easily.

 In both 2016 and 2013, HIV Outpatient Medical Care ranked second in total need.

Medical Care from a Specialist Table ES.4

Service Category Summary Results Medical Care from a Specialist

MEDICAL CARE FROM A SPECIALIST REFERRED BY YOUR HIV DOCTOR Total Sample

Total In-Care Out-of-Care

Service Need

If used, need met easily 73% 74% 69%

If not used, unfulfilled need 22% 22% 22%

No need 78% 78% 78%

Ranking

Total Need Rank 7 6 10

Unfulfilled Need Rank 12 11 16

Barriers to Care

"Difficult to get appointment" 42% 41% 44%

"High co-pay" 16% 23% 6%

 For the total consumer survey sample, twenty-seven percent reported their need was met with difficulty, and twenty-two percent reported an unfulfilled need.

 Out-of-care African American men and women reported the highest unmet need (excludes populations with small numbers of respondents).

Ryan White Planning Council of the Dallas Area 2016 Comprehensive HIV/AIDS Needs Assessment EXECUTIVE SUMMARY

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(For women) Outpatient OB/GYN Care Visits

Table ES.5 Service Category Summary Results

OB/GYN Care

OB/GYN CARE Total Sample

Total In-Care Out-of-Care

Service Need

If used, need met easily 91% 91% 90%

If not used, unfulfilled need 42% 35% 50%

No need 58% 65% 50%

Ranking

Total Need Rank 25 24 27

Unfulfilled Need Rank 30 33 29

Barriers to Care

"Difficult to get appointment" 28% 25% 30%

"Want To See A Female Doctor" 11% 12% 10%

 Ten percent of female respondents reported their need for this service was met with difficulty, and forty-two percent reported an unfulfilled need.

 Out-of-care Hispanic/Latino women (75%) and out-of-care African American women (55%) had the highest unmet need.

Food Bank/Home Delivered Meals Food Bank/Home Delivered Meals refers to the provision of actual food items, hot meals, or a voucher program to purchase food as well as the provision of essential non-food items that are limited to the following: personal hygiene products, household cleaning supplies, water filtration/purification systems in communities where issues of water safety exist. Food Bank/Home Delivered Meals was ranked third in overall need among the 35 services on the consumer survey and ranked eighth in unfulfilled need.

Table ES.6 Service Category Summary Results

Food Bank

FOOD BANK/HOME DELIVERED MEALS

Total Sample

Total In-Care Out-of-Care

Service Need

If used, need met easily 82% 82% 84%

If not used, unfulfilled need 36% 35% 37%

No need 64% 65% 63%

Ranking

Total Need Rank 3 3 4

Ryan White Planning Council of the Dallas Area 2016 Comprehensive HIV/AIDS Needs Assessment EXECUTIVE SUMMARY

4/19/2017 ES-16 New Solutions, Inc.

FOOD BANK/HOME DELIVERED MEALS

Total Sample

Total In-Care Out-of-Care

Unfulfilled Need Rank 8 9 8

Barriers to Care

"Location/Transportation" 41% 44% 37%

"Hours it is open" 15% 21% 9%

Considering need for Food Bank/Home Delivered Meals:

 Over one-third of consumers expressed unmet need for food bank/home delivered meals including 37% out-of-care and 35% in-care

 Out-of-care Youth and out-of-care Black/African American men and women had the highest unmet need both at 46%.

 Out-of-care MSM had 39% unmet need and in-care MSM had 36% unmet need.

 39% of in-care Hispanic/Latino men and women had an unmet need for food bank/home delivered meals.

 Total need for Food bank/home delivered meals was ranked in the top quartile of need in both 2013 and 2016.

Medical Case Management, Including Treatment Adherence Services Medical Case Management is the provision of a range of client-centered activities focused on improving health outcomes in support of the HIV care continuum.

Table ES.7 Service Category Summary Results

Medical Case Management

MEDICAL CASE MANAGEMENT Total Sample

Total In-Care Out-of-Care

Service Need

If used, need met easily 79% 79% 78%

If not used, unfulfilled need 27% 22% 34%

No need 73% 79% 66%

Ranking

Total Need Rank 5 5 5

Unfulfilled Need Rank 15 17 8

Barriers to Care

"Case manager not available/hard to reach" 33% 28% 38%

"Too much paperwork" 10% 16% 5%

 22% of in-care consumers reported an unfulfilled need; 34% of out-of-care consumers reported having an unfulfilled need.

 Out-of-care Hispanic/Latinos and Black MSMs reported the largest percentages of unfulfilled need for medical case management, 39% and 34% respectively.

Ryan White Planning Council of the Dallas Area 2016 Comprehensive HIV/AIDS Needs Assessment EXECUTIVE SUMMARY

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 In 2016, case management ranked fifth in terms of total need, up from tenth in 2013, and the unfulfilled need decreased from fourth to fifteenth

Medical Transportation (Transportation to Medical Care Bus Pass/Van Service) Medical Transportation is the provision of nonemergency transportation services that enables an eligible client to access or be retained in core medical and support services. Medical Transportation was the eighth ranked overall service need and the seventeenth most frequently identified unfulfilled need. In addition, in-care consumers ranked it eighth in overall need and sixteenth in unfulfilled need, while out- of-care consumers ranked it seventh in need and sixteenth in unfulfilled need.

Table ES.8 Service Category Summary Results

Medical Transportation

MEDICAL TRANSPORTATION Total Sample

Total In-Care Out-of-Care

Service Need

If used, need met easily 77% 79% 72%

If not used, unfulfilled need 19% 15% 27%

No need 81% 85% 73%

Ranking

Total Need Rank 8 8 7

Unfulfilled Need Rank 17 16 16

Barriers to Care

"Must take more than one bus to clinic" 25% 21% 28%

"Hard to take bus if ill" 17% 21% 13%

 Nineteen percent reported an unfulfilled need while 77% had their need easily met. Twenty-three percent reported a need that was met with difficulty.

 In-care Hispanic/Latino men and women and in-care MSM had the largest percentages of respondents reporting no need for medical transportation (excludes populations with small sample sizes responding).

 Among respondents that have not used this service in the past 12 months, out-of-care Youth had the highest unmet need.

 In-care MSM and in-care African-American MSM had the largest percentage with their need met easily (excludes populations with small n’s responding).

Housing Housing services provide transitional, short-term, or emergency housing assistance to enable a client or family to gain or maintain outpatient/ambulatory health services and treatment. Housing services include housing referral services and transitional, short-term, or emergency housing assistance. Transitional, short-term, or emergency housing provides temporary assistance necessary to prevent homelessness and to gain or maintain access to medical care.

Ryan White Planning Council of the Dallas Area 2016 Comprehensive HIV/AIDS Needs Assessment EXECUTIVE SUMMARY

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Emergency Financial Assistance for Rent and Mortgage or Utilities

Table ES.9 Service Category Summary Results

EFA for Rent/Utilities

EFA Rent/Utilities Total Sample

Total In-Care Out-of-Care

Service Need

If used, need met easily 54% 54% 53%

If not used, unfulfilled need 28% 28% 28%

No need 72% 72% 72%

Ranking

Total Need Rank 15 14 15

Unfulfilled Need Rank 3 3 3

Barriers to Care

"Limited Funding" 43% 40% 49%

"Too much paperwork" 14% 17% 10%

 Consumer survey respondents ranked the need for Emergency Assistance for Rent or Mortgage fifteenth among 35 service categories and third in unfulfilled need.

 In-care consumers ranked the need for Emergency Assistance for Rent or Mortgage fourteenth and third in unfulfilled need.

 Out-of-care respondents ranked the need fifteenth in need and the unfulfilled need was ranked third.

Long-Term Rental Assistance Voucher / Long-Term Housing

Table ES.10 Service Category Summary Results

Long-Term Housing

Long-Term Housing Total Sample

Total In-Care Out-of-Care

Service Need

If used, need met easily 45% 45% 44%

If not used, unfulfilled need 38% 35% 44%

No need 62% 65% 56%

Ranking

Total Need Rank 9 10 8

Unfulfilled Need Rank 2 2 2

Barriers to Care

Ryan White Planning Council of the Dallas Area 2016 Comprehensive HIV/AIDS Needs Assessment EXECUTIVE SUMMARY

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Long-Term Housing Total Sample

Total In-Care Out-of-Care

"Limited Funding" 21% 21% 20%

"Too much paperwork" 9% 9% 9%

 Consumer survey respondents ranked the need for Long-term Housing Assistance ninth among 35 service categories and second in unfulfilled need.

 In-care consumers ranked the need for Long-term Housing Assistance tenth and second in unfulfilled need.

 Out-of-care respondents ranked the need eighth in need, and the unfulfilled need was ranked second.

Mental Health Services Mental Health Services are the provision of outpatient psychological and psychiatric screening, assessment, diagnosis, treatment, and counseling services offered to clients living with HIV

Table ES.11 Service Category Summary Results

Mental Health Services

Mental Health Services Total Sample

Total In-Care Out-of-Care

Service Need

If used, need met easily 76% 79% 71%

If not used, unfulfilled need 16% 12% 22%

No need 84% 88% 78%

Ranking

Total Need Rank 13 13 13

Unfulfilled Need Rank 16 13 14

Barriers to Care

"Didn't know where to go" 59% 63% 55%

"Didn't want to use this service" 16% 11% 21%

 Nearly a third of consumers had been diagnosed with depression in the last 12 months.

 Out-of-care Hispanic/Latino men and women: 42% found their needs hard to meet.

 Among those in-care, MSMs had the highest percentage of consumers reporting a diagnosis of depression (31%); African-American men and women (26%) were the second highest percentage of consumers reporting this diagnosis.

 Among out-of-care consumers, 40% of Transgender respondents and 27% of Hispanic/Latinos had been diagnosed with depression.

Ryan White Planning Council of the Dallas Area 2016 Comprehensive HIV/AIDS Needs Assessment EXECUTIVE SUMMARY

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FOCUS GROUPS AND KEY INFORMANT INTERVIEWS The opinions and feedback expressed throughout focus group discussions and key informant interviews provided unique insight pertaining to the climate of the Dallas Planning Area. Several salient themes emerged including: an arduous enrollment process, a lack of health information exchange infrastructure across agencies including case coordination and statewide data system, a need to increase health education and availability for PrEP, and managing the disease without fundamental needs of daily living including housing, food and transportation, and delays in funding from the Administrative Agency. Focus Group participants and Key Informant interviewees collectively reported a need to streamline the enrollment process including a reduction in paperwork. The enrollment process may be simplified with inter-agency information sharing. The repetitive process of collecting the required documentation acts as a preeminent deterrent to clients receiving needed care and services. Participants reported frustration with a lack of health information exchange infrastructure across agencies including case coordination and the statewide AIRIES data system. Poor inter- and intra-agency communication inhibits an already difficult process. A reiterated theme was streamlining processes to resolve duplicative efforts. Pre-Exposure Prophylaxis, or PrEP, is a way for people who do not have HIV but who are at substantial risk of getting it to prevent HIV infection by taking a pill every day. PrEP is a powerful HIV prevention tool and can be combined with condoms and other prevention methods to provide even greater protection than when used alone. People who use PrEP must commit to taking the drug every day and seeing their health care provider for follow-up every three months. Discussion of lack of funding, access and education surrounding this highly beneficial prevention tool was pervasive. Universally, participants expressed issues surrounding both stigma and culture. Generally, PLWH are unable to manage their disease without fulfilling basic needs for housing, food and transportation. Repeatedly participants shared personal heart wrenching details of clients unable to receive care due to these instabilities. Housing was discussed as a barrier; a lack of available housing stock severely compromises the effectiveness of all other efforts to receive care. When asked to discuss how the Planning Council can improve its effectiveness in addressing client and agency barriers, issues of transparency and timeliness of funding were raised. Gaps in communication and variability in responses across agencies from the AA were discussed as road blocks to ensuring client services. Trust and accountability taint the relationship between the AA and agencies. One participant succinctly stated “Hold the AA accountable, making sure that when they get the money, the notifications are sent out in advance, on time and when they get the money there is a system in place that has the money hit the street early, and don’t take three to four months for the contract to be signed…” Universal themes expressed by Key Informant interview and Focus Group participants support findings identified across multiple areas of the primary research conducted. Although limited in number, the thoughts and opinions of these participants are indicative of the Dallas Planning Area’s most widespread concerns.

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Recommendations

1. Create an interagency task force to increase networking, strengthen communication and establish a forum for idea sharing and concerns.

2. Implement HRSA recertification data-sharing agreements across recipient and sub-recipients to reduce the burden across all entities including and most importantly, clients.

3. Establish a subcommittee to research robust health information exchange systems nationwide. 4. Request the Planning Council Manager and staff to draft a memorandum on limitations of the

ARIES data system and needs for modifications, to be reviewed by the CEO and ultimately submitted to the State for consideration.

5. Increase education, awareness and education of PrEP. Implement “out-of-the-box” ideas to reach target populations including, but not limited to social media.

6. Provide trainings to ensure sensitivity to client needs, eliminating stigma of the disease. Recognize the need for improved housing, transportation and nutrition as a foundation to successful engagement. Maintain and/or increase funding for HOPWA and RWHAP housing services.

7. Re-educate Planning Council members about the importance and role they play on the Council. Run a Planning Council retreat. Review funding and allocations process. Strategize effective means of communication for Planning Council members, grantees and sub-grantees to alleviate concerns regarding transparency of funding.

Ryan White Planning Council of the Dallas Area 2016 Comprehensive HIV/AIDS Needs Assessment 1-INTRODUCTION & METHODOLOGY

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1. INTRODUCTION AND METHODOLOGY INTRODUCTION The Ryan White Planning Council of the Dallas Area (RWPC) is responsible for planning services that support the use of Human Immunodeficiency Virus (HIV) medical care among people living with HIV/AIDS (PLWH) in a 12-county region. Although a full continuum of services is available through Ryan White HIV/AIDS Program (RWHAP) funded programs and community linkages, understanding consumer needs allows the RWPC to effectively plan to improve access, reduce barriers, enhance service quality and satisfaction and bring consumers who know their status and are not receiving medical care into the RWHAP system. Funding allocations follow effective planning, and this comprehensive needs assessment is designed to provide essential information for decision-making. Specific objectives include:

 Identify status and trends in the HIV/AIDS epidemic within the Dallas EMA/HSDA and Sherman Denison HSDA, focusing on recent changes and emerging affected populations;

 Identify consumer service needs, needs that are not currently being fulfilled, utilization patterns, and barriers to care;

 Obtain detailed information on PLWH with unmet need for medical care, including demographics, barriers, and strategies to connect to care;

 Construct the HIV Care Continuum (HCC) depicting the progression from HIV diagnosis to viral load suppression;

 Evaluate the system for and rate of linking PLHWA into medical care;

 Identify and evaluate the system of HIV/AIDS care, evaluating current capacity, gaps, and barriers (including, but not limited to eligibility barriers) in the continuum and treatment cascade. This will include both HIV/AIDS service providers and providers of services that PLWH use; and

In order to accomplish these objectives, the following activities were undertaken:

 A detailed survey of 697 PLWH of which 457 were in-care and 240 were out-of-care/returned to care;

 Four in-depth focus groups were conducted with direct personnel, Planning Council Members/Staff, providers, and consumers. Supplemental interviews were conducted for each focus group to ensure adequate feedback;

 A survey of 13 Ryan White funded providers including a detailed profile of provider capacity with questions regarding the impact of healthcare reform;

 Surveillance and sociodemographic data about the population of the region and status of the epidemic obtained from the Texas Department of State Health Services (DSHS) and the U.S. Census;

 An inventory of funded and non-funded Ryan White local providers offering services that could expand the RWPC defined continuum of care (HCC);

 Key informant interviews with community leaders, healthcare leaders, and Ryan White funded providers.

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Definition of Service Area This needs assessment focuses on the RWPC’s three planning areas—the Dallas EMA, the Dallas HSDA and the Sherman-Denison HSDA. These include 12 counties: Collin, Cooke, Dallas, Denton, Ellis, Fannin, Grayson, Henderson, Hunt, Kaufman, Navarro, and Rockwall. Oversight of the Needs Assessment Direct oversight of the needs assessment was provided by RWPC’s Planning and Priorities (P&P) Committee and the Needs Assessment Work Group. Others providing input and assistance included:

 RWPC Manager and staff;

 Dallas County Department of Health and Human Services Administrative Agency (AA) staff. Priority Populations Priority populations for the Comprehensive Needs Assessment were determined by the Planning & Priorities Committee and included:

 African-Americans;

 Hispanic/Latino;

 Men who have sex with men;

 Transgender Persons;

 Youth (13-24 years of age). METHODOLOGY Regional Demographic Profile The data for the regional demographic profile and the Dallas County profile were obtained from the U.S. Census Bureau. These data include:

 Population counts from 2010 Census (American Community Survey) and estimates for the 2012 and 2015 population by county;

 Socioeconomic indicators such as income, poverty, and race/ethnicity;

 Disproportional impact. Epidemiologic Profile The data for this epidemiological profile were obtained from the Texas Department of State Health Services (DSHS). They reflect information on the epidemic in the Dallas EMA, the Dallas HSDA, and the Sherman-Denison HSDA collected during routine surveillance. Data include:

 HIV and AIDS morbidity and mortality data, focusing on data trends between 2011 and 2015.  The number of people living with HIV/AIDS (prevalence);  New diagnoses (incidence);  Mortality;  Disease status (HIV vs AIDS);  Variations by gender, age and race/ethnicity;

 Co-morbid conditions;

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 Unmet need estimates which identify the number of people who are HIV/AIDS-positive and “out- of-care/returned to care”;8

 HIV Care Continuum, linkage and retention in care.

Consumer Survey

A survey of 697 people living with HIV was conducted from December 26, 2016 through February 17, 2017. Respondents included 457 (66%) consumers receiving HIV medical care and 240 (34%) who were out-of-care/returned to care. Survey Design The survey was designed to obtain information about in-care, out-of-care/returned to care and special populations. It included questions in the following areas:

 Initial screening of PLWH to determine whether they were in-care or out-of-care/returned to care and met the survey sampling criteria;

 Reasons for being out-of-care, problems associated with HIV medical care and/or for dropping out of care;

 Information about diagnosis and linkage to care;

 Barriers to HIV medical care;

 Current housing situation and housing service options;

 Use of and need for 35 different services most of which can be funded by Ryan White and are included in the RWPC’s Continuum of Care;

 Substance abuse treatment service needs;

 Ranking of the most important/critical service needs. The survey drew upon questions from a variety of previously validated instruments. Sources for the 2016 consumer survey included:

 2007, 2010 and 2013 Dallas Area Consumer Survey of the Comprehensive Needs Assessment;

 Final wording for several questions as modified by the Needs Assessment Work Group. The final survey was translated into Spanish by an experienced translator well versed in HIV programs. Copies of the English and Spanish versions of the consumer survey used in this study are included in Appendix 1.1.

Out-of-care Criteria. (1) Not currently receiving HIV medical care, with at least 12 months since the last medical appointment. This is the HRSA definition of “out-of-care” which is “no HIV medical care, no viral load or CD4 counts and no antiretroviral medications in the last 12 months.” These people may or may not be receiving other Ryan White or HIV services. (2) Diagnosed between 2013 and 2016 that failed to link to care within six months of diagnosis. They may currently be in care. (3) Diagnosed between 2013 and 2016, linked to care after diagnosis but dropped out-of-care for at least six months. They may now be back in care. (4) Dropped out-of-care for at least 12 months but are now back in care. They should have been back in care for no more than two years.

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On-Line Survey Administration The consumer survey was implemented using eCOMPAS, a web-based on-line survey provided by RDE Systems. Following review and approval by the RWPC and the RWPC Manager, the final English and Spanish surveys were provided to RDE Systems by New Solutions, Inc. (NSI). RDE Systems engineers developed the on-line instrument with the necessary skip logic, making it as easy as possible for consumers to complete the survey via computer. eCOMPAS features included:

 Immediate tabulation of consumers completing the survey. English and Spanish versions were aggregated, and real-time results were available to “fine tune” the sample.

 Ease of administration. The RWPC consumer survey has historically had complex skip logic, requiring significant field team training and monitoring including “checking” each survey as completed. RDE programmed all skip logic to allow consumers seamless access to the questions.

In addition, the survey used Audio Computer Assisted Self Interview (ACASI) which allowed consumers to hear the questions being read. This reduced concern about low literacy consumers not appropriately completing the survey. Both English and Spanish versions of the survey were recorded by local individuals to ensure regional dialect.

 English survey reading was provided by the RWPC Manager.

 Spanish survey reading was provided by the AIDS Interfaith Network, Inc. Agencies with Wi-Fi access were eligible for web-based survey administration. NSI provided four computers to reduce hardware barriers for administration at various survey sites. Computers were allocated to various sites by the RWPC Manager based on the number of anticipated participants and agency expressed need. Paper Survey Administration Despite anticipated difficulties with data validation, incentive distribution and data entry logistics, the Needs Assessment Work Group felt strongly that there was a need to offer a hard-copy survey administration supplemental to on-line administration. The Work Group expressed concerns including: consumer lack of computer access, consumer having little or no comfort level using a computer (even with assistance and translation) and an inability to administer to the out-of-care population using technology due to environmental constraints. Paper surveys were administered at the discretion of providers at individual sites with several sites opting to administer solely hard-copy surveys. No identifiable consumer information was provided to New Solutions, Inc. Additionally, many out-of-care surveys completed “on-the-street” were administered on- paper. RWPC and NSI Staff assisted agencies with completing data entry of paper surveys. Approximately 40% (273) of respondents completed paper surveys included in the sample. There were an additional 15 paper surveys collected and not included in the final sample as they did not meet criteria for completion.

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Survey Sampling Approach A pure random sample was not feasible as it requires that every PLWH in the Dallas region has an equal probability of selection for the survey. Therefore, a stratified convenience sample was employed. The sampling plan was developed based upon demographic percentages identified in the epidemic profile. The sample consisted of 697 valid responses stratified for gender, race, ethnicity, age and residence. As such, it represented 3.52% of PLWH population in the EMA and was generalizable at 95% confidence level and confidence interval of 1.59.9 Survey Administration RWPC and NSI staff visited and engaged multiple agencies to secure survey administration outside the scope of traditional RW funded providers. Diligent efforts yielded three non-RW funded providers, an increase from the one non-RW funded provider from the 2013 administration. The RWPC Program Manager, RWPC staff, and Needs Assessment Work Group members supported survey administration at provider locations across the HSDAs. RWPC and NSI staff were also available by phone for technical assistance. All surveying opportunities were publicized with English and Spanish flyers at locations targeted to PLWH including pharmacies, food banks, shelters, and the public library.

 RWPC staff scheduled time to visit the following locations: Prism Health North Texas (formerly known as AIDS Arms), Parkland (Amelia Court and Bluitt-Flowers), AIDS Healthcare Foundation, AIDS Interfaith Network, Inc., Health Services North Texas Plano and Denton, Callie Clinic.

 Prism Health North Texas Jefferson Towers’ staff administered the survey during their holiday celebration.

 Resource Center supported survey administration in their computer lab.  Remote survey administration was publicized with flyers and take away cards specifying the

website. Consumer Stipends Upon survey completion, in-care consumers received a $10 WalMart gift card from the provider locations. Consumers completing the survey remotely could bring the completion number to Dallas County Health and Human Services to claim their incentive card. Out-of-care/returned to care consumers received a $25 WalMart gift card for their participation and completed survey. In addition, a recruitment $25 WalMart gift card was provided to the individual who secured the out-of-care survey.

9 The confidence level indicates the percentage at which responses represent the true population. A 95% confidence level means you can be 95% certain that responses are accurate or that a 5% change exists that the responses do not represent the entire population. The confidence interval represents the margin of error, plus-or-minus, between the recorded responses and the true value of the measurement. This sample’s confidence interval is +/- 1.59 which means that if our sample selects an answer, you can be “sure” that, if you had asked the question of the entire relevant population, the same answer is within 1.59 points of the entire population picking that answer.

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Data Analysis Using on-line survey data, immediate tabulation of consumer responses was possible. During the field work period, respondent profiles were analyzed daily to ensure adequate sample composition. Profiles considered included the number surveyed by priority population, sample demographics, transmission mode, and county of residence. After February 17, 2017, the survey close date, the database was reviewed and cleaned prior to analysis. Surveys completed through Question 44 were included in the sample as completing through Question 44 enabled a determination of the consumer’s status as in-care or out-of-care. The data set was exported from eCOMPAS and manipulated into tabular and graphic results for analysis and presentation. Frequency and cross-tabulation analyses were conducted with data presented overall and for each priority population. Respondent Overview

 The gender distribution of the surveyed sample resembled the population utilizing services. The survey sample included 75% male respondents and 23% female compared to 77% males and 22% females infected in the region. The Consumer Survey sample had a larger distribution of Transgender; however, the sample size was relatively small.

 The epidemic included 20% female and 80% male. No transgender individuals were reflected in the epidemiology data. Those receiving services were 0.7% transgender, and those in the survey represented 2.2%.

Table 1.1

Comparison of Consumer Survey Sample with Regional Epidemic Gender

Gender

Epidemiology n=19,793

ARIES n=9,609

Consumer Survey n=697

Female 19.8% 22.3% 22.8%

Male 80.2% 77.0% 75.0%

Transgender NA 0.7% 2.2%

 Considering race, Whites/Caucasians were under-represented in the survey sample as compared to the epidemic, but closely resembled the in-care population. Whites/Caucasians comprised 32% of the regional epidemic, 25% of the survey sample and 25% of the population receiving services.

 Black/African-Americans made up 41% of the epidemic and 49% of those receiving services. Black/African-Americans were over-represented at 56% of the survey sample.

 Hispanics comprised 22% of the epidemic, 24% of those receiving services and were under- represented at 16% of those surveyed.

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Table 1.2

Comparison of Consumer Survey Sample with Regional Epidemic Race/Ethnicity

Race/Ethnicity

Epidemiology n=19,793

ARIES n=9,609

Consumer Survey n=697

White/Caucasian 31.6% 25.4% 24.7%

Black/African- American

41.3% 48.9% 55.5%

Hispanic/Latino 22.1% 23.9% 16.2% *Number of PLWH with known Race/Ethnicities.

In terms of transmission modes:

 Survey respondents’ most frequently identified transmission mode was male-to-male sex (MSM) with 50% identifying this mode. This compared to 68% reported in the epidemic and 56% of those in care.

 Heterosexual transmission was identified by 32% of survey respondents compared to 20% of the epidemic and 32% in care.

 Shared needles/injecting drug use (IDU) was identified by 6% of those surveyed. This compared to 7% IDU in the regional epidemic and 3% of those in care.

Table 1.3

Comparison of Consumer Survey Sample with Regional Epidemic Transmission Mode

Transmission Mode

Epidemiology n=19,793

ARIES n=9,609

Consumer Survey n=697

MSM 67.9% 55.9% 50.1%

IDU 6.9% 3.3% 6.0%

Heterosexual 20.3% 31.5% 31.9%

Considering age of respondents, the sample was older than the regional epidemic because, in part, the survey covered only adult PLWH.

 The sample included approximately 3% of PLWH in the 13 to 24 age range, as compared to less than 5% found in the epidemic and 4% receiving services.

 The 25 to 44 age group comprised 43% of the epidemic and 36% of the survey sample.

 The 45+ age group was 52% of the epidemic and 61% of the sample.

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Table 1.4

Comparison of Consumer Survey Sample with Regional Epidemic Age Group

Age Group

Epidemiology n=19,793

ARIES n=9,609

Consumer Survey n=697

<2 0.0% 0.1% 0.0%

2-12 0.1% 0.4% 0.0%

13-24 4.7% 4.1% 3.2%

25-44 43.4% 45.5% 36.1%

45+ 51.7% 49.9% 60.7%

Note: Totals may not sum to 100% due to rounding.

Survey Limitations As is the case with the administration of large scale surveys, data limitations must be recognized. Many were minimized by having the survey read to consumers with low literacy and by automated skip logic so that question sequencing was done seamlessly for consumers. Nevertheless, potential data limitations included:

 Misunderstanding or misinterpreting words or terms. This was minimized by previous survey validation and review of survey wording by a health literacy expert.

 Forced selection of responses without the options of “not applicable,” “don’t know” or “refused.”

 The possibility of selecting contradictory responses which was minimized using the on-line survey skip logic.

 Large numbers of surveys completed in hard-copy, thereby increasing possibility of data entry errors and incomplete surveys that received incentive cards.

Key Informant Interviews Nine in-depth qualitative Key Informant Interviews were conducted with community experts, to provide insight on the nature of problems and give recommendations for solutions. Interviews included community leaders, healthcare leaders, and Ryan White funded providers. Key Informant participation was solicited by the RWPC Program Manager and Staff. New Solutions, Inc. support staff contacted and scheduled Interviews scheduled from December 12, 2016 through December 20, 2016. Key Informant Interviews were approximately 45 minutes in duration and conducted by telephone. Key Informant Interviews enable the primary research to gain in-depth, detailed information to enhance the understanding of the client needs, including special populations, service gaps, barriers to care, reasons for consumers not receiving care, changes in the epidemic since 2013, and suggestions to improve care within the current funding environment. Refer to Appendix 1.3 for the Key Informant Interview Guide.

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Key Informant Interview Analysis For all Key Informant Interviews, verbatim transcriptions were created from voice recordings. All responses were grouped by theme and commonality of response. Results are included in this report by theme, service category, and relevant priority population. Limitations of Key Informant Data The key informant interview discussions may have been limited by:

 Selecting the “right” key informants may be difficult so they represent diverse backgrounds and

viewpoints

 Scheduling interviews with busy and/or hard-to-reach respondents

 The potential for the interviewer to unwittingly influence the responses given by informants.

 The validity of the data can sometimes be difficult to prove.

Provider Focus Group Discussions Four in-depth focus groups were conducted with: Direct Personnel, Planning Council Members/Staff, Providers, and Consumers. Focus group participation was solicited and secured by the RWPC Program Manager and Staff. Focus groups were scheduled from December 19, 2016 through December 21, 2016 and conducted in the UT Southwestern Medical Center conference room and at the Dallas County Human Services offices. Due to the holiday season, attendance was not optimal and thus supplemental phone interviews were conducted for each focus group to ensure adequate feedback. Provider focus groups were planned to gain in-depth, detailed information to enhance the understanding of the client needs, including special populations, service gaps, barriers to care, reasons for consumers not receiving care, changes in the epidemic since 2013, and suggestions to improve care within the current funding environment. Refer to Appendix 1.2 for the provider focus group guide.

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Provider Focus Group Analysis For both consumer and provider focus groups, verbatim transcriptions were created from voice recorders. All responses were grouped by theme and commonality of response. Results are included in this report by theme, service category, and relevant priority population. Limitations of Provider Focus Group Data The provider focus group discussion was limited by:

 All participants of the case manager focus groups worked for Ryan White funded agencies.

 Not all agencies were represented.

 Provider focus group responses represent opinions, beliefs and experiences of the participants.

 Limited attendance due to holiday season. Profile of Provider Capacity and Capability Survey Design and Sample The Profile of Provider Capacity and Capability (Provider Profile) was designed to be completed by the 13 Ryan White funded providers. Its design was based on the 2013 Profile of Provider Capacity survey. Specifically, it included:

 Services offered, waiting time for first appointment, available capacity with current resources and programs targeting specific populations.

 Recommendations to improve service delivery for the organization’s clients/patients.

 Barriers to care. The survey was made available on-line, and the link was e-mailed to the 13 Ryan White funded providers. A 100% response rate was achieved. Follow-up methods included e-mails and limited telephone contact. Refer to Appendix 1.4 for a copy of the survey instrument. Data Analysis

Survey Monkey was utilized for tabular and graphic analysis. An exported database was developed for further analysis of free response questions. Many of the questions were open-ended and sought opinions. These responses were compiled and analyzed to determine similarities and differences among providers. Data Limitations Limitations associated with the provider survey include:

 Questions were asked for an entire agency (such as hours of operation, payer mix) so responses could not be assigned to a specific service category.

 Analyses by service category were often based on a small number of respondents.

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Resource Inventory Survey Design and Sample The 2015-2016 Source Book of the Community Council of Greater Dallas provided the foundation for the resource inventory. This directory is updated annually and included much of the detailed information about agencies needed by the RWPC. Using the 2015-2016 Source Book, a list of providers offering services that are part of the Planning Council’s continuum of care was compiled in an excel spreadsheet. It included provider name, address, contact person and service categories relevant to PLWH and the care continuum. The data from the 2015- 2016 Source Book were supplemented with:

 The 2015 HIV Handbook of North Dallas developed by Parkland Health & Hospital System HIV Service Department.

 Information received from rural Ryan White funded agencies about their referral partners.  Review of the RWPC 2013 Resource Inventory was conducted to include any service providers

that were not captured in the two sources named above, but are still in operation. Data Analysis Data analysis was conducted using Excel. Information is presented by service category in Chapter 3 of this report. GAP Analysis The gap analysis utilizes the results of the consumer survey along with the provider focus groups, out-of- care consumer interviews, key informant interviews, provider survey and the provider inventory to inform the analysis. In doing so, the following issues were considered:

 How highly was the service ranked by survey respondents;

 The unfulfilled need ranking of respondents;

 The current availability and capacity as reported by the provider survey and inventory;

 The degree of difficulty consumers report when attempting to access the service;

 The percent of respondents experiencing barriers, and qualitative information obtained through interviews and provider focus groups.

Suggestions for Future Surveys Following the final presentation of the report to the Ryan White Planning Council of the Dallas Area, suggestions will be documented and provided back to the Council members, representatives of the Administrative Agency and Dallas EMA providers, under separate cover.

Ryan White Planning Council of the Dallas Area 2016 Comprehensive HIV/AIDS Needs Assessment 2-REGIONAL DEMOGRAPHIC PROFILE

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2. REGIONAL DEMOGRAPHIC PROFILE There are 12 counties in the Dallas and Sherman-Denison HSDAs, with a total estimated population of 5,033,408 in 2015. Considering the HIV Service Delivery Areas (HSDAs) in this region:

 Dallas County is the largest with 2,553,385 persons, followed by Collin County with a total population of 914,127 and Denton with 780,612 in 2015.

 The remaining counties range in population from 163,000 to 33,700 persons. Population growth between 2010 and 2015 shows:

 The population of the region, over this 5-year span, grew by around 11%.

 The populations of Denton grew by nearly 18%, Collin County by nearly 17%, Rockwall by 16%, Kaufman by 11%, and Ellis by more than 9%.

 The population of the counties in Sherman-Denison grew, but at a much smaller rate (<10%) over the study period.

 Continued growth was noted in population estimates for 2015 in all counties in the Dallas EMA.

Figure 2.1 The Dallas Planning Area (Dallas EMA, Dallas HSDA, Sherman-Denison HSDA)

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Table 2.1 Population - Dallas EMA, Sherman-Denison HSDA, Dallas HSDA

2010, 2012, 2015

County

2010 Population

2012 Population

2015 Population

2010 - 2012 Population

Change

2012 - 2015 Population

Change

2010 - 2015 Population

Change

# # # % % %

Dallas EMA 4,309,052 4,511,825 4,786,696 4.7 6.1 11.1

Collin* 782,341 837,480 914,127 7.0 9.2 16.8

Dallas* 2,368,139 2,456,444 2,553,385 3.7 3.9 7.8

Denton* 662,614 708,300 780,612 6.9 10.2 17.8

Ellis* 149,610 153,779 163,632 2.8 6.4 9.4

Henderson 78,532 78,953 79,545 0.5 0.7 1.3

Hunt* 86,129 87,266 89,844 1.3 3.0 4.3

Kaufman* 103,350 106,675 114,690 3.2 7.5 11

Rockwall* 78,337 82,928 90,861 5.9 9.6 16

Dallas HSDA 4,278,255 4,398,031 4,755,474 4.7 8.1 11.2

Collin* 782,341 837,480 914,127 7.0 9.2 16.8

Dallas* 2,368,139 2,456,444 2,553,385 3.7 3.9 7.8

Denton* 662,614 708,300 780,612 6.9 10.2 17.8

Ellis* 149,610 153,779 163,632 2.8 6.4 9.4

Hunt* 86,129 87,266 89,844 1.3 3.0 4.3

Kaufman* 103,350 106,675 114,690 3.2 7.5 11

Navarro 47,735 48,087 48,323 0.7 0.5 1.2

Rockwall* 78,337 82,928 90,861 5.9 9.6 16

Sherman-Denison HSDA

193,229 194,083 198,389 0.4 2.2 2.7

Cooke 38,437 38,790 39,229 0.9 1.1 2.1

Fannin 33,915 33,692 33,693 -0.7 0.0 ‐0.7

Grayson 120,877 121,601 125,467 0.6 3.2 3.8

Regional Total 4,550,016 4,753,995 5,033,408 4.5 5.9 2.3

*County overlapped by Dallas EMA & Dallas HSDA coverage areas

2010 Populations from Census 2010 SF 1

2015 Populations from Census 2010 ACS, 5-year via https://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=PEP_2015_PEPANNRES&prodType=table Accessed 1/5/17

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Figure 2.2

INCOME AND POVERTY The counties with the lowest per capita incomes tend to have the highest percentage of families living below poverty.

 These include Dallas, Hunt, Henderson, and Navarro.

 Conversely, those with the highest per capita income have poverty rates that are among the lowest. These include Collin and Rockwall counties.

Table 2.2

Income Per Capita & Percentage of Families Living Below Federal Poverty Level (FPL)

By County 2015

Income per capita ($) % Living Below FPL

Dallas EMA

Collin* 38,883 5.7

Dallas* 27,605 15.9

Denton* 34,914 5.8

Ellis* 26,357 9.4

Henderson 22,613 13.7

Hunt* 21,888 14.6

Kaufman* 24,944 10.7

Rockwall* 36,163 5.3

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Income per capita ($) % Living Below FPL

Dallas HSDA

Collin* 38,883 5.7

Dallas* 27,605 15.9

Denton* 34,914 5.8

Ellis* 26,357 9.4

Hunt* 21,888 14.6

Kaufman* 24,944 10.7

Navarro 20,697 15.9

Rockwall* 36,163 5.3

Sherman‐Denison HSDA

Cooke 26,742 11.2

Fannin 20,545 12.9

Grayson 25,033 12.3

*County overlapped by Dallas EMA & Dallas HSDA coverage areas Source: 2014 ACS 5‐Year Estimates via https://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_15_5YR_DP03&prodType=table Accessed 1/5/17

RACE AND ETHNICITY Race and ethnicity vary across the region.

 The farther north in the region, the larger the percentage of Whites/Caucasians. This ranges from 79.7% in Fannin (Sherman-Dennison HSDA) to 31.5% in Dallas.

 Blacks/African-Americans range from 21.8% in Dallas to 2.4% in Cooke (Sherman-Denison).

 The highest concentration of Hispanic/Latinos reside in the counties of Dallas (39.0%), Ellis (24.7%), and Navarro (25.2%).

 The Sherman-Denison HSDA has a higher concentration of non-minority populations than found in the Dallas HSDA.

Table 2.3 Race/Ethnicity by County, EMA/HSDA

2015

EMA/HSDA/County

Total Population

White Black Hispanic Asian

# % % % %

Dallas EMA 4,786,696

Collin* 914,127 60.8 8.9 15.0 12.4

Dallas* 2,553,385 31.5 21.8 39.0 5.6

Denton* 780,612 62.1 8.7 18.8 7.3

Ellis* 163,632 63.9 8.8 24.7 0.6

Henderson 79,545 79.5 6.5 11.7 0.6

Hunt* 89,844 73.5 8.4 14.6 1.2

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EMA/HSDA/County

Total Population

White Black Hispanic Asian

# % % % %

Kaufman* 114,690 68.1 9.3 18.8 0.8

Rockwall* 90,861 72.8 5.3 16.7 2.3

Dallas HSDA 198,389

Collin* 914,127 60.8 8.9 15.0 12.4

Dallas* 2,553,385 31.5 21.8 39.0 5.6

Denton* 780,612 62.1 8.7 18.8 7.3

Ellis* 163,632 63.9 8.8 24.7 0.6

Hunt* 89,844 73.5 8.4 14.6 1.2

Kaufman* 114,690 68.1 9.3 18.8 0.8

Navarro 48,323 58.4 13.3 25.2 0.7

Rockwall* 90,861 72.8 5.3 16.7 2.3

Sherman-Denison HSDA 4,755,474

Cooke 39,229 77.1 2.4 16.9 0.7

Fannin 33,693 79.7 6.8 10.3 0.6

Grayson 125,467 77.1 5.9 12.3 1.1 *County overlapped by Dallas EMA & Dallas HSDA coverage areas Source: 2015 ACS 5-year estimates via https://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_15_5YR_DP05&prodType=table Accessed 1/5/17

Figure 2.3

Ryan White Planning Council of the Dallas Area 2016 Comprehensive HIV/AIDS Needs Assessment 2-REGIONAL DEMOGRAPHIC PROFILE

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Figure 2.4

Figure 2.5

Ryan White Planning Council of the Dallas Area 2016 Comprehensive HIV/AIDS Needs Assessment 2-REGIONAL DEMOGRAPHIC PROFILE

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HIV/AIDS PREVALENCE IN THE REGION In 2015, there were 19,768 PLWH in the Dallas HSDA, and 226 in the Sherman-Denison HSDA.

 The number of PLWH varies significantly within the HSDA and within each county in the HSDA.

 As noted in the table below, the preponderance of the epidemic is centered in Dallas County which represents nearly 82% of the PLWH in the Dallas EMA.

Table 2.4

Population and People Living with HIV/AIDS (PLWH) EMA/HSDA, County

2015

County

2015 Population 2015 HIV/AIDS Prevalence

n = 20,105

# # % of Regional

Epidemic

Dallas EMA 4,786,696 19,793 98.4

Collin* 914,127 1,544 7.7

Dallas* 2,553,385 16,387 81.5

Denton* 780,612 1,157 5.8

Ellis* 163,632 235 1.2

Henderson 79,545 111 0.6

Hunt* 89,844 105 0.5

Kaufman* 114,690 175 0.9

Rockwall* 90,861 79 0.4

Dallas HSDA 4,755,474 19,768 98.3

Collin* 914,127 1,544 7.7

Dallas* 2,553,385 16,387 81.5

Denton* 780,612 1,157 5.8

Ellis* 163,632 235 1.2

Hunt* 89,844 105 0.5

Kaufman* 114,690 175 0.9

Navarro 48,323 86 0.4

Rockwall* 90,861 79 0.4

Sherman-Denison HSDA 198,389 226 1.1

Cooke 39,229 25 0.1

Fannin 33,693 27 0.1

Grayson 125,467 174 0.9 *County overlapped by Dallas EMA & Dallas HSDA coverage areas 2015 Populations from 2015 ACS 5-year estimates 2015 HIV/AIDS Prevalence from: Texas HIV Surveillance Report Data Accessed 1/5/17

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Figure 2.6

DALLAS COUNTY DEMOGRAPHICS AND HIV/AIDS PREVALENCE Dallas County is the most populous county in the 12-county region and has the highest prevalence of HIV/AIDS. A detailed review of the county’s demographics and HIV prevalence by geographic region follows. Stemmons Corridor

 Stemmons Corridor (Stemmons) has the highest number of PLWH in the county.

 Stemmons Corridor has 172,865 residents, or 6.8% of the Dallas County population.

 Nearly 44% of Stemmons Corridor residents are Latino and White, while 7.7% are Black/African- Americans.

 Unemployment in 2015 was 5.9%, and per capita income was $39,800; 12.6% were living below FPL.

 25.6% of Stemmons residents have not completed high school. Southeast Dallas

 Southeast Dallas has the second highest number of PLWH.

 Southeast Dallas (SE Dallas) is the most populous community with 382,399 residents or 15% of Dallas County’s population.

 More than half of SE Dallas residents (53.5%) are Hispanic/Latino. 23.8% are Black/African- American and 20.9% are White.

 In 2015, SE Dallas has low socioeconomic status with per capita income of $18,199, unemployment of 8.9%, 25.7% of residents living below FPL, and low educational attainment.

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South Dallas

 South Dallas has 1868 PLWH and ranks third county-wide.

 South Dallas, with 159,156 residents, comprises 6.2% of Dallas County’s population.

 Black/African-American is the majority racial group, 66.8%. Hispanic/Latino is 29%, White is 3.9%.

 South Dallas has the lowest economic indicators of all Dallas County communities:  Per capita income of $15,245  Unemployment of 12.5%  28.7% below FPL

 Nearly 30% of South Dallas adults have not graduated from high school. North Dallas

 North Dallas has 1,867 PLWH, similar to South Dallas, and ranks fourth county-wide.

 North Dallas is home to 252,940 people which is nearly 10% of the Dallas County total.

 North Dallas is predominantly White, 65.5%, followed by Latino, 22.7%. Black/African-American and Asian-American/others are 7.5% and 4.3% respectively.

 North Dallas had the highest 2015 per capita income of all the communities, $58,749. Despite 4.5% unemployment, 10.4% of residents were living below the FPL in 2015.

Northeast Dallas

 Northeast Dallas ranked fifth in terms of residents living with HIV/AIDS.

 Northeast Dallas (NE Dallas) has 264,057 residents, comprising 10.3% of Dallas County’s population.

 Northeast Dallas closely matches the race/ethnicity of Dallas County with 42.1% Hispanic/Latino, 29.1% White, and 20.6% Black/African-American.

 In 2015, per capita income was $22,134, unemployment was 8.2%, and 21.0% were living below the FPL.

Northwest Dallas

 Northwest Dallas has 1,127 PLWH.

 Northwest Dallas has 247,569 residents, comprising 9.7% of the Dallas County population,

 Northwest Dallas has the largest Asian-American/other population in the County, 19.4%. Other racial/ethnic groups include: White 43%, Hispanic/Latino 25.3% and Black/African-American 12.3%.

 Northwest Dallas has one of the highest economic indicators of all communities.  Per capita 2015 income was the second highest of the communities, $41,884.  Unemployment was very low at 5.1%.  9% of residents were living below the FPL.

 It also has the highest percentage of adults who have completed high school, 90.1%.

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Figure 2.7

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Ryan White Planning Council of the Dallas Area 2016 Comprehensive HIV/AIDS Needs Assessment 2-REGIONAL DEMOGRAPHIC PROFILE

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Figure 2.10 Figure 2.11 Concentrations of PLWH within Dallas County As noted in the Figure 2.12 below, the number of PLWH varies throughout Dallas County. The preponderance of PLWH reside in areas that surround downtown Dallas – the Stemmons Corridor (3,234), Southeast Dallas (1,997), North Dallas (1,867), South Dallas (1,868), Northeast Dallas (1,789), and Northwest Dallas (1,127). See Appendix 2.1 for zip codes that make up these areas.

Figure 2.12

Ryan White Planning Council of the Dallas Area 2016 Comprehensive HIV/AIDS Needs Assessment 2-REGIONAL DEMOGRAPHIC PROFILE

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There are six zip codes within the city of Dallas which, when combined, contain over 25% of PLWH in the region. The largest portion of PLWH reside in Dallas zip code 75219, located in Stemmons Corridor region where 1,295 PLWH are identified; this comprises 8.0% of the total cases in that region.

 PLWH in Dallas 75219 (1,295) and 75235 (539) make up 56.7% of all PLWH in Stemmons Corridor (3,234).

 Dallas zip codes 75243 (744) and 75231 (548) comprise 72.2% of PLWH in Northeast Dallas (1,789).

 Dallas 75216 (528) comprises 28.3% of PLWH in the South Dallas region (1,868), while Dallas 75228 (488) comprises 24.4% of PLWH in Southeast Dallas.

Figure 2.13

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Table 2.5 Geographic Concentration of PLWH

Top Dallas Zip Codes 2015

Zip Code PLWH Region

75219 1,295 Stemmons Corridor

75243 744 NE Dallas

75231 548 NE Dallas

75235 539 Stemmons Corridor

75216 528 South Dallas

75228 488 Southeast Dallas

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3. EPIDEMIOLOGY PROFILE SUMMARY Data for this epidemiological profile were obtained from the Texas Department of State Health Services (DSHS). It reflects the number of people living with HIV/AIDS (PLWH) in the Dallas Eligible Metropolitan Area (EMA), Dallas HIV Service Delivery Area (HSDA), and the Sherman-Denison HSDA. The data do not include those unaware of their HIV infection or those who tested HIV-positive solely through an anonymous HIV test. MONITORING THE EPIDEMIC Prevalence Increasing In 2015, there were 19,793 people known to be living with HIV/AIDS in the Dallas EMA, 19,768 in the Dallas HSDA, and 226 in the Sherman-Denison HSDA. Between 2011 and 2015, the epidemic grew by 20% in the Dallas EMA, 17% in the Dallas HSDA, and 28% in the Sherman-Denison HSDA. Prevalence rates increased by 15% in the Dallas EMA, 17% in the Dallas HSDA and 25% in the Sherman-Dennison HSDA. Table 3.1 presents the annual prevalence, and Figure 3.1 depicts the steady increase in the Dallas EMA during this time.

Table 3.1 PLWH

Dallas EMA, Dallas HSDA, Sherman-Denison HSDA 2011-2015

EMA/HSDA 2011 2012 2013 2014 2015

AAGR* 2011- 2015

# Rate # Rate # Rate # Rate # Rate # Rate

Dallas EMA 16,561 358.2 17,661 392 18,201 396.6 18,968 404.7 19,793 413.5 4.6% 3.7%

Dallas HSDA 16,942 386.8 17,651 394.5 18,188 398.9 18,958 407.2 19,768 415.7 3.9% 1.8%

Sherman- Denison HSDA

176 90.9 179 92.1 199 102.4 215 109.7 226 113.9 6.5% 5.9%

*AAGR refers to Average Annual Growth Rate

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Figure 3.1

Incidence Trends In the last five years, the highest number of new diagnoses in the Dallas EMA occurred in 2011, with 1,648 people diagnosed with HIV or AIDS. Incidence has declined in the Dallas EMA through the five-year period.

 From 2011 to 2015, incidence of HIV/AIDS decreased 11.6% in the Dallas EMA and 11.4% in the Dallas HSDA.

 During this period, the rate of new cases decreased from 37.4/100,000 to 30.5/100,000 in the Dallas EMA, while the rate decreased from 37.7/100,000 to 30.8/100,000 in the Dallas HSDA.

 Sherman-Denison HSDA experienced an increase of 6 cases (37.5%) between 2011 and 2015.

Table 3.2 New Diagnoses of HIV or AIDS

Dallas EMA, Dallas HSDA, Sherman-Denison HSDA 2011-2015

EMA/HSDA 2011 2012 2013 2014 2015

# Rate # Rate # Rate # Rate # Rate

Dallas EMA 1,648 37.4 1,534 34.0 1,501 32.7 1,535 32.8 1,457 30.5

Dallas HSDA 1,651 37.7 1,537 34.3 1,498 31.5 1,536 32.3 1,463 30.8

Sherman- Denison HSDA

16 8.3 20 10.3 18 9.1 26 13.1 22 11.1

16,561

17,661 18,201

18,968 19,793

15,000

17,000

19,000

21,000

2011 2012 2013 2014 2015

PLWH Trend Dallas EMA 2011-2015

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Figure 3.2

Mortality Declining Mortality statistics lag behind incidence reporting and are released only through 2013.

 From 2009 through 2013, mortality among PLWH in the Dallas EMA declined 5.6% with variation during this period.

 The largest decrease in mortality among PLWH (20.2%) occurred in the Dallas EMA from 2011 to 2012. Statistics for the Sherman-Denison HSDA are normally less than five and more variable due to the small population size.

Table 3.3

Deaths in PLWH Dallas EMA, Dallas HSDA, Sherman-Denison HSDA

2009-2013

EMA/HSDA 2009 2010 2011 2012 2013

Dallas EMA 232 247 238 190 219

Dallas HSDA 232 247 237 189 216

Sherman-Denison HSDA 2 6 4 4 4

1,648

1,534 1,501

1,535

1,457

1,300

1,350

1,400

1,450

1,500

1,550

1,600

1,650

1,700

1,750

1,800

2011 2012 2013 2014 2015

New Diagnoses Trend Dallas EMA 2011-2015

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Figure 3.3

HIV/AIDS Disease Status In the Dallas EMA, the proportion of PLWH with an AIDS diagnosis in 2011 was 54.0%. By 2015, this percentage declined to 51.8%.

 The increase in the overall epidemic also contributed to general increases in the number and rate of both HIV and AIDS cases.

 Between 2011 and 2015, HIV cases increased 25.2% and AIDS cases increased by 14.6%.

 The number of AIDS cases decreased 2.2 percentage points as a percentage of total cases, indicating that individuals may be diagnosed sooner.

Table 3.4

Comparison of Disease Status Dallas EMA 2011-2015

Disease Status 2011 2015 2011-2015

# Percent Rate # Percent Rate % Change in

Cases

HIV 7,612 46.0 164.6 9,534 48.2 199.2 25.2

AIDS 8,949 54.0 193.5 10,259 51.8 214.3 14.6

County Populations and Profiles Considering the epidemic throughout the 12-county region:

 Dallas County continues to be the epicenter of the regional epidemic with 81.5% of PLWH residing there.

 Collin, Denton, and Ellis counties follow with 7.7%, 5.8%, and 1.2% of the PLWH population, respectively.

232

247 238

190

219

180

200

220

240

260

280

300

2009 2010 2011 2012 2013

Deaths in PLWH Trend Dallas EMA 2009-2013

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 All other counties have less than 1% of the region’s PLWH, with Cook and Fannin counties having the smallest numbers at 0.1% of the regional epidemic.

Table 3.5 Population, PLWH, Percent Regional Epidemic

Counties in Dallas EMA, Dallas HSDA, Sherman-Denison HSDA 2015

County 2015 Population 2015 HIV/AIDS Prevalence

# # % of Regional Epidemic

Collin 914,127 1,544 7.7%

Cooke 39,229 25 0.1%

Dallas 2,553,385 16,387 81.5%

Denton 780,612 1,157 5.8%

Ellis 163,632 235 1.2%

Fannin 33,693 27 0.1%

Grayson 125,467 174 0.9%

Henderson 79,545 111 0.6%

Hunt 89,844 105 0.5%

Kaufman 114,690 175 0.9%

Navarro 48,323 86 0.4%

Rockwall 90,861 79 0.4%

PLWH AND NEW DIAGNOSES BY GENDER The Texas DSHS eHARS registry currently reports gender as male or female. Transgender identification is not maintained. It is important to recognize, however, that transgender PLWH exist nationwide and by most accounts are on the rise. Alternate data sources, i.e., ARIES Statistical Analysis Report (STAR) identifies 69 transgender persons in the Dallas and Sherman-Denison HSDAs, comprising less than 1% (0.7%) of all PLWH receiving RWHAP services. This epi-profile follows TDSHS gender reporting of male or female. The distribution of cases by gender in the Dallas EMA was stable between 2011 and 2015. Cases in Sherman-Denison increased for men and women over the same period.

 Approximately 80% of living cases are male in both the Dallas EMA and Sherman-Denison HSDA.  As the epidemic grew during this period, an additional 2,565 men and 667 women were

living with HIV/AIDS in the Dallas EMA during the same period.  Sherman-Denison HSDA saw a decrease in the distribution of PLWH among males and an

increase in the distribution among females of 3.5 percentage points between 2011 and 2015.

 From 2011 to 2015, annual trends in new diagnoses varied for both genders in the Dallas EMA.  New diagnoses decreased 3.2% for men and 11.9% for women during this period.  There was a slight increase in the distribution among males from this period of 1.5

percentage points. This is in line with the slight increase of 0.5 percentage points in the distribution of new diagnoses among MSM transmission category.

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Table 3.6 PLWH by Gender

Dallas EMA, Sherman-Denison HSDA 2011-2015

Gender

Dallas EMA Sherman-Denison HSDA

2011 2015 2011 2015

# % Rate # % Rate # % Rate # % Rate

Male 13,311 80.4 569.7 15,876 80.2 674.1 153 82.3 159.5 178 78.8 180.4

Female 3,250 19.6 142.1 3,917 19.8 161.1 33 17.7 33.8 48 21.2 48.1

Table 3.7

New HIV Diagnoses by Gender Dallas EMA 2011-2015

Gender 2011 2012 2013 2014 2015

# Rate # Rate # Rate # Rate # Rate

Male 837 38.5 778 35.0 777 34.4 868 37.6 810 34.4

Female 193 8.6 172 7.5 173 7.4 199 8.4 170 7.0

Race/Ethnicity From 2011 to 2015, the number of PLWH increased in all major race/ethnicity groups except White/Caucasian, which experienced a decline of 63 persons in the Dallas EMA. Increases among all racial/ethnic groups were noted in the Sherman-Denison HSDA during this period.

 In the Dallas EMA, Black/ African-Americans have the highest prevalence rate in the region, at 1,011.2 per 100,000.

 The rate among Black/African-Americans is more than triple the rate of every other major race/ethnicity.

 PLWH who are Black/African-American increased by 24.7% in the Dallas HSDA and 28.1% in Sherman-Denison HSDA.

 Hispanic/Latinos had the largest percentage increase in PLWH at 34.8% in the Dallas EMA.  In Sherman-Denison HSDA, the percentage increase for Hispanic/Latino was 27.8% from

the time period between 2011-2015.

 In the Dallas EMA, the percentage of PLWH that are White/Caucasian has declined between 2011 and 2015.

 White/Caucasians experienced the only decrease in PLWH in the region, and the percentage of PLWH that are white decreased by 6.5 percentage points.

 In Sherman-Denison, White/Caucasian experienced an increased in prevalence of 16.8%.

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Table 3.8

PLWH by Race/Ethnicity Dallas EMA 2011, 2015

Race/ Ethnicity

Dallas EMA

2011 2015 2011-2015

# %* Rate # %* Rate % Change

White 6,307 38.1 277.1 6,245 31.6 282.1 -1.0

Black 6,558 39.6 1011 8,178 41.3 1036.3 24.7

Hispanic 3,243 19.6 229.4 4,372 22.1 312.0 34.8

Other 223 1.3 78.1 238 1.2 62.2 6.7

*Percentage does not equal 100% in aggregate because PLWH cases labeled unknown race/ethnicity are not included

Table 3.8 (continued)

PLWH by Race/Ethnicity Sherman-Denison HSDA

2011, 2015

Race/Ethnicity

Sherman-Denison HSDA

2011 2015 2011-2015

# %* Rate # %* Rate % Change

White 125 67.2 80.9 146 64.6 94.4 16.8

Black 32 17.2 288.8 41 18.1 347.0 28.1

Hispanic 18 9.7 76.3 23 10.2 85.6 27.8

Other 3 1.6 68.2 5 2.2 99.4 66.7

*Percentage does not equal 100% in aggregate because PLWH cases labeled unknown race/ethnicity are not included

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Figure 3.4

New diagnoses among White/Caucasians, Black/African-Americans, and Hispanic/Latinos did not change significantly between 2011 and 2015.

 Black/African-Americans had the largest number and rate of new HIV/AIDS diagnoses every year between 2011 and 2015.

 The difference in the number of cases between White/Caucasians and Black/African-Americans ranged from 190 in 2013 to 255 in 2015.

 In 2015, the incidence rate among Blacks/African-Americans was more than six times that of White/Caucasians, and more than three times that of Hispanic/Latinos.

Table 3.9

New HIV/AIDS Diagnoses by Race/Ethnicity Dallas EMA 2011-2015

Race/Ethnicity

2011 2012 2013 2014 2015

# Rate # Rate # Rate # Rate # Rate

White 246 11.6 246 11.4 236 10.9 262 12.0 222 10.0

Black 447 62.9 437 59.7 426 56.8 479 62.3 477 60.4

Hispanic 278 21.9 232 17.8 245 18.4 274 20.1 236 16.8

Other 16 5.3 13 4.1 13 3.8 24 6.6 19 5.0

* Percentage does not equal 100% in aggregate because PLWH cases labeled unknown race/ethnicity are not included.

38.1 39.6

19.6

1.3

31.6

41.3

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0

5

10

15

20

25

30

35

40

45

White Black Hispanic Other

P e

rc e

n ta

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o f

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PLWH by Race/Ethnicity Dallas EMA 2011,2015

2011 2015

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DISPROPORTIONATE IMPACT In a comparison of the general population with PLWH and new diagnoses of HIV, Black/African Americans experienced a disproportionate impact in 2015 in the Dallas EMA.

 While Blacks made up 16% of the population in the Dallas EMA, the percentage of PLWH in the EMA was disproportionally higher at 41.3%.

 The percentage of PLWH that are Black (41.3%) exceeded that of Whites (31.6%) and Hispanics (29.0%) by 9.7 and 19.2 percentage points, respectively.

 As noted in the table below, Blacks made up 46.1% of new diagnoses in the Dallas EMA in 2015  The percentage of new cases among Blacks in the Dallas EMA was over 20 percentage

points higher than Whites (25.2%) and 19.7 percentage points among Hispanics (26.4%).

Table 3.10 Comparison of Race – General Population, PLWH, New Diagnoses

Dallas EMA 2015

Figure 3.5

47.0%

16.0%

29.0%

8.0%

31.6%

41.3%

22.1%

1.2%

25.2%

46.1%

26.4%

2.3%

0%

10%

20%

30%

40%

50%

White Black Hispanic Other Race

Comparison of Race/Ethnicity - Population, PLWH, New Diagnoses

Dallas EMA 2015

Population HIV/AIDS Prevalence HIV/AIDS Incidence

Population HIV/AIDS Prevalence HIV/AIDS Incidence

White 47.0% 31.6% 25.2%

Black 16.0% 41.3% 46.1%

Hispanic 29.0% 22.1% 26.4%

Other Race 8.0% 1.2% 2.3%

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Transmission Mode “Mode of exposure” or “transmission mode” indicates the most likely way that someone became infected with HIV.

 Male sex with men (MSM) continues to be the dominant transmission mode throughout the region.

 In 2015, MSM represented the transmission mode of over two-thirds of PLWH in the Dallas EMA. In the Sherman-Denison HSDA, MSM was the mode of exposure for over half (51.9%) of those living with the virus.

 In the Dallas EMA, heterosexual exposure was the second most frequently identified transmission mode (20.3%).

 From 2011 to 2015, heterosexual contact had the largest percentage increase in the Dallas EMA (21.4%).

 In the Sherman-Denison HSDA, injecting drug use (IDU) or MSM combined with IDU was the transmission mode of 23.8% of PLWH in 2015.

 Between 2011 and 2015, heterosexual contact in the region increased PLWH by 64.5%, the highest change for any mode of transmission category.

Table 3.11

PLWH by Transmission Mode Dallas EMA, Sherman-Denison HSDA

2011-2015

Transmission Mode

Dallas EMA Sherman-Denison HSDA

2011 2015 2011-2015 2011 2015 2011-2015

# % # % % Change # % # % % Change

MSM 11,154 67.3 13,432 67.9 20.4 97 52.0 117 51.9 20.6

IDU 1,247 7.5 1,375 6.9 10.3 26 14.0 28 12.6 7.7

MSM/IDU 695 4.2 809 4.1 16.4 27 14.7 25 11.2 -7.4

Heterosexual 3,315 20.0 4,024 20.3 21.4 31 16.6 51 22.5 64.5

Pediatric 126 0.8 131 0.7 4.0 3 1.6 2 0.9 -33.3

Other 25 0.2 22 0.1 -12.0 2 1.1 2 0.9 0.0

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Figure 3.6

Trends in new diagnoses in the Dallas EMA demonstrate:

 MSM continues to account for most new HIV/AIDS diagnoses in 2015 (73.7%), and has risen 0.5 percentage points since 2011.

 Heterosexual transmission has the next highest percentage share with 18% in 2015, which fell from 20.6% in 2011.

 The percentage change in both MSM transmission and heterosexual contact transmission reflects a slight shift to MSM incidence over the 2011-2015 period.

 The distribution of new diagnoses by transmission mode was relatively stable between 2011 and 2015, with an increase in injecting drug use transmissions over the period that did experience fluctuations and a decrease in heterosexual transmissions that also experienced year-to-year fluctuations.

Table 3.12 New HIV/AIDS Diagnoses by Transmission Mode

Dallas EMA 2011-2015

Transmission Mode

2011 2012 2013 2014 2015

# % # % # % # % # %

MSM 754 73.2 701 73.8 718 75.6 785 73.6 722 73.7

IDU 43 4.2 40 4.2 27 2.9 37 3.5 52 5.3

MSM/IDU 17 1.7 17 1.8 22 2.3 30 2.9 26 2.6

Heterosexual 212 20.6 190 20.0 181 19.0 212 19.8 176 18.0

Pediatric 3 0.3 2 0.2 2 0.2 3 0.3 4 0.4

67.9%

6.9%

4.1%

20.3%

0.7% 0.1%

HIV/AIDS Transmission Mode Dallas EMA

2015

MSM

IDU

MSM/IDU

Heterosexual

Pediatric

Other

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Aging PLWH PLWH in both the Dallas EMA and Sherman-Denison HSDA are becoming older. While new infections continue among all age groups, the increase in prevalence within the older population is at least partially due to the continued effect of improved treatment therapies and survival.

 From 2011 to 2015 in the Dallas EMA, the share of PLWH that were age 55+ increased by 5.5 percentage points.

 During the same time period, the share of PLWH fell in the 35-44 and 45-54 age groups fell 4.4 and 2.1 percentage points, respectively.

 In 2015, people age 55+ accounted for 20.4% of PLWH in the Dallas EMA and 25.2% in Sherman- Denison HSDA. Between 2011 and 2015, the number of PLWH ages 55+ increased by 63.9% in the Dallas EMA and 58.3% in the Sherman-Denison HSDA.

Table 3.13

PLWH by Age Group Dallas EMA, Sherman-Denison HSDA

2011, 2015

Age Group

Dallas EMA Sherman-Denison HSDA

2011 2015 2011- 2015

2011 2015 2011- 2015

# % Rate # % Rate %

Change # % Rate # % Rate %

Change

Under 2 3 0.0 2.2 5 0.0 3.7 66.7 0 0.0 0 0 0.0 0 0.0

2 - 12 40 0.2 5.6 20 0.1 2.5 -50.0 1 0.5 3.6 1 0.4 3.6 0.0

13 - 24 876 5.3 118.0 933 4.7 117.1 6.5 6 3.2 19.4 9 4.0 29.1 50.0

25 - 34 2,949 17.8 432.9 3,848 19.4 543.8 30.5 28 15.1 126.6 34 15.0 144.3 21.4

35 - 44 4,696 28.4 564.2 4,757 24.0 681.1 1.3 48 25.8 210.9 52 23.0 230.1 8.3

45 - 54 5,532 33.4 791.0 6,191 31.3 940.9 11.9 67 36.0 237.9 73 32.3 277.1 9.0

55+ 2,465 14.9 304.5 4,039 20.4 400.2 63.9 36 19.4 63.3 57 25.2 91.9 58.3

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Figure 3.7

In considering the aging of PLWH, it is important to consider whether these are new diagnoses or are people aging with the disease due to improvements in treatment. Age at diagnosis can help answer this question.

 Over the past five years, an average of 210 older adults, ages 45 and older, were diagnosed, ranging from 196 in 2015 to 231 in 2011.

 The 25-34 age range saw the largest increase in new diagnoses between 2011 and 2015. In 2011, a total of 316 people were diagnosed in this age range; in 2015, this age range accounted for 338 new diagnoses.

Table 3.14 New HIV/AIDS Diagnoses by Age Group

Dallas EMA 2011-2015

Age Group 2011 2012 2013 2014 2015

# Rate # Rate # Rate # Rate # Rate

Under 2 3 2.3 1 0.8 1 0.8 1 0.8 3 2.2

2 - 12 0 0 1 0.1 1 0.1 2 0.3 1 0.1

13 - 24 249 33.8 247 32.8 240 31.3 271 34.6 260 32.6

25 - 34 316 47.6 274 40.6 324 47.6 366 52.7 338 47.8

35 - 44 231 34.8 226 33.5 181 26.5 209 30.3 182 26.1

45 - 54 164 26.5 128 20.4 145 22.8 149 23.1 139 21.1

55+ 67 8 73 8.3 58 6.3 69 7.1 57 5.6

0.2

5.3

17.8

28.4

33.4

14.9

0.1

4.7

19.4 24.0

31.3

20.4

0

5

10

15

20

25

30

35

40

< 2 2 - 12 13 - 24 25 - 34 35 - 44 45 - 54 55+

PLWH by Age Group 2011-2015 Dallas EMA

2011 2015

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UNMET NEED DSHS’s calculation of unmet need (percentage of PLWH not receiving medical care) for the Dallas EMA and the State of Texas are shown below with detail by disease status, gender, race/ethnicity, age, and exposure mode. Refer to the HIV Care Continuum, below, for additional discussion.

 The Dallas EMA unmet need estimates find 21% of PLWH not receiving HIV medical care. This compares with 23% for Texas overall.

 Considering gender in the Dallas EMA, 20% of men are out-of-care, compared to 22% of women. Comparatively, the 2015 PLWH with unmet need in Texas by gender was 23% for men and 22% for women.

 In the Dallas EMA, Black/African Americans have the highest PLWH with unmet need at 24%. Races and ethnicities other than White/Caucasian, Black/African American, and Hispanic/Latino also have PLWH with an unmet need at 24%. These are followed by an unmet need of 23% for Hispanic/Latino.

 Among different age groups in the Dallas EMA, the 35-44 age group has the largest percentage with unmet need at 23%. The next highest percentage is in the 25-34 age group at 22%.

 Among mode of transmission categories, “adult other” has the highest percentage of PLWH out- of-care, 27%. This is followed by heterosexual and IDU, which both experience unmet need at 24%.

Table 3.15 PLWH with Unmet Need for Medical Care

Gender, Race/Ethnicity, Age, Mode of Transmission Dallas EMA and Texas

2015

Dallas EMA Texas

# % %

Total 4,129 21% 23%

Disease Status

HIV 2,439 26% 29%

AIDS 1,690 16% 18%

Gender

Female 879 22% 22%

Male 3,250 20% 23%

Race/Ethnicity

White 1,040 17% 19%

Black 1,932 24% 25%

Hispanic 1,003 23% 25%

Other 58 24% 27%

Unknown 96 13% 13%

Age

0-1 1 20% 18%

02-12 4 20% 19%

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Dallas EMA Texas

# % %

13-24 190 20% 22%

25-34 853 22% 24%

35-44 1,102 23% 25%

45-54 1,146 19% 21%

55+ 833 21% 23%

Mode of Transmission

MSM 2,640 20% 22%

IDU 334 24% 27%

MSM/IDU 158 20% 22%

Heterosexual 963 24% 24%

Pediatric 29 22% 27%

Adult Other 6 27% 25%

Unmet need by transmission mode, race/ethnicity, and gender finds:

 Excluding “Other”, Black/African-Americans MSM have the highest unmet need (23%) when compared to Hispanic/Latino (22%) and White/Caucasian (16%).

 Male IDUs have a higher unmet need when compared to females. Hispanic/Latino male IDUs have the highest unmet need in this transmission category, at 38%. White women have the highest unmet need in the IDU transmission category at 23%.

 Unmet need among those with heterosexual transmission finds:  Hispanic/Latino men have the highest percentage of PLWH with an unmet need (32%).  White/Caucasian women (21%) have a higher unmet need than men (20%).  Black/African-American women have the highest unmet need among racial/ethnic

categories (24%) of other racial or ethnic categories.

Table 3.16 PLWH with Unmet Need for Medical Care

By Gender, Transmission Mode, and Race/Ethnicity Dallas EMA

2015

Dallas EMA Male Female

# % Unmet Need # % Unmet Need

Grand Total 3,250 20 879 22

MSM

White 828 16 . .

Black 986 23 . .

Hispanic 724 22 . .

Other 37 24 . .

Unknown 64 13 . .

Total 2,640 20 . .

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Dallas EMA Male Female

# % Unmet Need # % Unmet Need

IDU

White 45 29 31 23

Black 99 24 83 21

Hispanic 46 38 19 22

Other 2 66 2 30

Unknown 2 12 4 12

Total 194 28 139 21

MSM/IDU

White 52 16 . .

Black 66 22 . .

Hispanic 34 23 . .

Other 0 14 . .

Unknown 6 15 . .

Total 158 20 . .

Heterosexual

White 18 20 60 21

Black 151 29 530 24

Hispanic 57 32 117 23

Other 5 20 8 21

Unknown 6 18 12 9

Total 236 28 727 23

Pediatric

White 3 33 2 17

Black 11 30 6 15

Hispanic 4 31 2 13

Other . . 1 100

Unknown . . . .

Total 18 29 11 16

Unmet need by disease status finds PLWH with HIV have higher unmet need in all categories when compared to PLWH with AIDS. The exceptions are Hispanics, those individuals 45 years or older, as well as the IDU and MSM/IDU transmission categories.

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Table 3.17 PLWH with Unmet Need for Medical Care

Disease Status by Gender, Race/Ethnicity, Age, Mode of Transmission Dallas EMA

2015

Dallas EMA

HIV AIDS

# % # %

Total 2,439 26 1,690 16

Gender

Female 558 28 321 16

Male 1,881 25 1,369 16

Race/Ethnicity

White 574 19 466 14

Black 1,284 31 648 16

Hispanic 495 25 508 21

Other 38 28 20 20

Unknown 48 15 48 11

Age

0-1 1 20 . .

02-12 4 21 . .

13-24 167 22 23 13

25-34 688 26 165 13

35-44 684 28 418 18

45-54 556 23 590 15

55+ 339 25 494 18

Mode of Transmission

MSM 1,579 24 1,060 16

IDU 157 30 177 21

MSM/IDU 76 26 82 16

Heterosexual 600 31 362 18

Pediatric 25 28 4 9

Adult Other 2 33 4 25

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SEXUALLY TRANSMITTED DISEASES Within the general population, chlamydia is the most prevalent sexually transmitted disease (STD), infecting 21,581 residents of the Dallas EMA.

 Chlamydia infections are more prevalent among women (71.1%) than men (28.7%).

 Over 60% of cases are among youth ages 13-24.

 Blacks/African-Americans represent 27.0% of those infected with Chlamydia in 2015. Both Whites/Caucasian and Hispanics/Latino represent 19.5% of those infected in the Dallas EMA.

Gonorrhea infected 6,883 Dallas EMA residents in 2015.

 58.4% of gonorrhea infections occurred in men, 41.3% in women.

 39.4% of gonorrhea infections occurred among Blacks/African-Americans. Whites/Caucasian and Hispanics/Latino accounted for 20.3% and 13.9%, respectively.

 Over half (53.0%) of gonorrhea infections are among youth ages 13-24. 1,013 Dallas EMA residents contracted Syphilis in 2015.

 87.5% of syphilis infections were among men, 12.4% were among women.

 Nearly 40% of infections occurred among Blacks/African-American (39.6%).

 22.9% of syphilis cases were among youth, 36.5% among the 25-34 age group, and 21.1% occurred in those 35-44 years.

Table 3.18

STDs by Gender, Race/Ethnicity, Age Dallas EMA

2015

Year Chlamydia Gonorrhea Syphilis (1)

# % Rate # % Rate # % Rate

Total 21,581 100 1337.2 6,883 100 505.6 1,013 100 87.7

Sex

Male 6,186 28.7 262.7 4,023 58.4 170.8 886 87.5 37.6

Female 15,342 71.1 631 2,846 41.3 117 126 12.4 5.2

Unknown 53 0.2 0 14 0.2 0 1 0.1 0

Race/Ethnicity

White 4,204 19.5 189.9 1,399 20.3 63.2 309 30.5 14

Black 5,826 27 738.2 2,712 39.4 343.7 401 39.6 50.8

Hispanic 4,198 19.5 299.5 955 13.9 68.1 244 24.1 17.4

Other 419 1.9 109.5 117 1.7 30.6 21 2.1 5.5

Unknown 6,934 32.1 0 1,700 24.7 0 38 3.8 0

Age Group

<2 13 0.1 9.6 4 0.1 3 . . .

2-12 9 0 1.2 6 0.1 0.8 . . .

13-24 13,941 64.6 1750.2 3,650 53 458.2 232 22.9 29.1

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Year Chlamydia Gonorrhea Syphilis (1)

# % Rate # % Rate # % Rate

25-34 5,774 26.8 816 2,053 29.8 290.1 370 36.5 52.3

35-44 1,317 6.1 188.6 670 9.7 95.9 214 21.1 30.6

45-54 407 1.9 61.8 371 5.4 56.4 134 13.2 20.4

55+ 100 0.5 9.9 123 1.8 12.2 63 6.2 6.2

(1) Includes Primary, Secondary, and Early Latent Syphilis

Comparing PLWH co-infected with STDs at the time of diagnosis, in 2015, syphilis accounts for nearly half of all cases (43.9%), 8.3% of gonorrhea cases, and 2.0% of chlamydia cases in the Dallas EMA.

Table 3.19 Co-Morbidity of HIV/AIDS & STD Total Cases

Dallas EMA 2015

Dallas EMA

Chlamydia Gonorrhea Syphilis*

# % # % # %

Total 440 2.0 571 8.3 498 49.2

* Includes Primary, Secondary, and Early Latent Syphilis

Gonorrhea is the most prevalent co-morbid sexually transmitted disease, infecting 571 Dallas EMA residents with HIV/AIDS in 2015.

 93.9% of gonorrhea infections occurred in men, 6.1% in women.

 44.3% of gonorrhea infections occurred among Blacks/African-Americans. Whites/Caucasian and Hispanics/Latino accounted for 25.4% and 23.3%, respectively.

 19.4% of gonorrhea infections are among youth ages 13-24. Four hundred ninety-eight Dallas EMA HIV/AIDS infected residents contracted Syphilis in 2015.

 98.4% of syphilis infections were among men with HIV/AIDS, 1.6% were among women with HIV/AIDS.

 Nearly 40% of infections occurred among Blacks/African-American (36.7%).

 10.0% of syphilis cases were among youth, 39.0% among the 25-34 age group, and 25.4% occurred in those 35-44 years.

Chlamydia is the least prevalent co-morbid sexually transmitted disease (STD), infecting 440 HIV/AIDS positive residents of the Dallas EMA.

 Chlamydia infections are more prevalent among HIV/AIDS positive men (87.7%) than women (12.3%).

 Over 40% of co-morbid cases are among those ages 25-34.

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 Blacks/African-Americans represent 47.3% of those co-morbidly infected with Chlamydia in 2015. Whites/Caucasian and Hispanics/Latino represent 22.7% and 22.8% of those infected in the Dallas EMA, respectively.

Table 3.20

Co-Morbidity of HIV/AIDS and Selected STD Cases By Gender, Race/Ethnicity, Age, Mode of Transmission

Dallas EMA 2015

Chlamydia Gonorrhea Syphilis*

# % # % # %

Gender

Female 54 12.3 35 6.1 7 1.6

Male 386 87.7 536 93.9 491 98.4

Race/Ethnicity

White 100 22.7 145 25.4 143 28.7

Black 208 47.3 253 44.3 183 36.7

Hispanic 109 24.8 133 23.3 137 27.5

Other 7 1.6 2 0.4 4 0.8

Unknown 16 3.6 38 6.7 31 6.2

Age

13-24 81 18.4 111 19.4 50 10.0

25-34 190 43.2 256 44.8 189 38.0

35-44 91 20.7 107 18.7 127 25.5

45-54 64 14.5 76 13.3 91 18.3

55+ 14 3.2 21 3.7 41 8.2

Mode of Transmission

MSM 355 80.7 495 86.7 461 92.2

IDU 11 2.5 13 2.3 7 1.4

MSM/IDU 18 4.0 25 4.3 23 4.6

Heterosexual 53 12 38 6.6 8 1.6

Pediatric 4 0.9 1 0.2 1 0.2

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Tuberculosis was a co-morbid condition among 2.0% of PLWH in the Dallas EMA.

Table 3.21 Tuberculosis Co-Morbidity

Dallas EMA 2015

Total PLWH TB Co-Morbidity % TB Co-Morbidity

Dallas EMA 19,793 395 2.0

HIV CARE CONTINUUM Texas DHSHS developed the 2015 HIV/AIDS Care Continuum (HCC) for Dallas EMA, Dallas HSDA and Sherman-Denison HSDA.1 Along with the Continuum or “cascade,” a “Healthier Community” graphical display was developed to further depict linkage and retention in care. The following presents the TDSHS information. Fact sheets compiled by TSDHS with additional graphical displays are contained in Appendix 3.1. Definitions used in the HCC and Healthier Community calculations:

 HIV+ Individuals at end of 2015 = No. of HIV+ individuals (alive) residing in Texas, Dallas EMA, Dallas HSDA or Sherman-Dennison HSDA at the end of 2015.

 At Least One Visit in 2015 = No. of PLWH with a met need (at least one: medical visit, ART prescription, VL test, or CD-4 test) in 2015, otherwise referred to as “linked to care.”

 Retained in Care = No. of PLWH with at least 2 visits or labs, at least 3 months apart or suppressed at end of 2015.

 Achieved Viral Suppression at end of 2015 = No. of PLWH whose last viral load test value of 2015 was <= 200 copies/mL.

In 2015, all three regions reported relatively consistent performance for the four indicators of the HCC.

 Dallas EMA and Dallas HSDA results were nearly identical. Sherman-Dennis reported higher linkage (84%), retention (79%) and suppression rates (68%).

 As a measure of favorable outcomes as a result of HIV care, viral suppression was achieved by 86% to 88% of patients with two or more medical visits in 2015.

 The Dallas EMA, Dallas HSDA and Sherman-Denison HSDA surpassed viral suppression rates when compared to the statewide average.

1 Sources: Enhanced HIV AIDS Reporting System (eHARS) as of July 2, 2015, Medicaid, ARIES, ADAP, and private payers. Prepared by Program Planning and Evaluation Group, HIV/STD Branch at the Texas Department of State Health Services, August, 2016.

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Table 3.22 HIV Care Continuum

Dallas EMA, Dallas HSDA and Sherman-Denison HSDA 2015

PLWH At Least One Visit Retained in Care Suppressed

% Suppressed

of Those Retained

# % # % # % # % %

Dallas EMA 19,793 100.0% 15,664 79%

79.1% 79%

14,281 72.2% 12,533 63%

63.3% 63%

87.8%

Dallas HSDA

19,768 100.0% 15,641 79.1% 14,260 72.1% 12,513 63.3% 87.8%

Sherman- Denison

226 100.0% 189 83.6% 179 79.2% 154 68.1% 86.0%

Texas 82,745 100.0% 63,706 77.0% 57,074 69.0% 48,632 59.0% 85.2%

Figure 3.8

19,793 15,664 14,281 12,533

100% 79% 72% 63%

0% 20% 40% 60% 80% 100%

0

5,000

10,000

15,000

20,000

HIV+ Individuals Living, 2015

At least one visit/lab

Retained In Care Achieved Viral Suppression

HIV Care Continuum Dallas EMA

2015

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Figure 3.9

Figure 3.10

Gender

 Across the Dallas EMA, Dallas HSDA, and Sherman-Denison HSDA, similar percentages of male and female PLWH had a met need in 2015.

 75% of women and 80% of men in the Sherman-Denison HSDA were retained in care, which is higher than 70% of women and 73% of men in both the Dallas EMA and Dallas HSDA.

 Of those retained in care in the Sherman-Denison HSDA, the percentage suppressed was highest for women at 86%; and the Dallas HSDA had the highest for men at 88%. For both genders, the percent suppressed of those retained exceeded 75% for the Dallas EMA, Dallas HSDA, and Sherman-Denison HSDA.

226 189 179 154

100% 84% 79%

68%

0%

20%

40%

60%

80%

100%

0

50

100

150

200

Individuals living with HIV, 2015

At least one visit/lab

Retained In Care Achieved Viral Suppression

HIV Care Continuum Sherman Denison HSDA

2015

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Race/Ethnicity

 Every race/ethnicity category reported over 75% of PLWH a met need in the Dallas EMA, Dallas HSDA, and Sherman-Denison HSDA.

 Sherman-Denison HSDA had the highest percentage of Whites (82%), Blacks (68%) and Hispanics (78%) retained in care. The Dallas EMA had 79% of Whites, 67% of Blacks, and 71% of Hispanics retained in care, which was nearly identical to the percentages in the Dallas HSDA.

 More than half (56%) of Blacks in the Dallas EMA and Dallas HSDA were virally suppressed in 2015, while only 49% of Blacks in Sherman-Denison HSDA were virally suppressed.

Age

 Approximately 80% of PLWH from each age group reported a met need in each geography.

 The percentage suppressed of those retained in care in the Dallas EMA, Dallas HSDA, and Sherman-Denison HSDA exceeded 75% in each age category.

Transmission Mode

 By transmission mode, high percentages of PLWH were identified with met need in 2015.

 In the Dallas EMA, the injection drug-use transmission mode had the lowest percentage of PLWH retained in care (68%). Injection drug-use and MSM/IDU had the lowest number retained in care in the Sherman-Denison HSDA at 72%, while heterosexual transmission was the transmission category in the Dallas HSDA with the lowest percentage retained in care (69%).

Table 3.23 HIV Care Continuum by Gender, Race/Ethnicity, Age, Transmission Mode

Dallas EMA 2015

PLWH

At Least One Visit

Retained in Care Suppressed % Suppressed

of those Retained

# % # % # % # %

ALL PLWH 19,793 100.0 15,664 79.1 14,281 72.2 12,533 63.3 80.0%

Gender

(F)Female 3,917 19.8 3,038 77.6 2,743 70.0 2,354 60.1 77.5%

(M)Male 15,876 80.2 12,626 79.5 11,538 72.7 10,179 64.1 80.6%

Race/Ethnicity

White, not Hispanic 6,245 31.6 5,205 83.3 4,904 78.5 4,492 71.9 86.3%

Black, not Hispanic 8,178 41.3 6,246 76.4 5,492 67.2 4,596 56.2 73.6%

Hispanic 4,372 22.1 3,369 77.1 3,112 71.2 2,773 63.4 82.3%

Other 238 1.2 180 75.6 166 70.1 157 66.0 87.2%

Unknown 760 3.8 664 87.4 607 79.9 515 67.8 77.6%

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PLWH

At Least One Visit

Retained in Care Suppressed % Suppressed

of those Retained

# % # % # % # %

Age

0-24 955 4.8 759 80.0 581 60.8 446 46.7 76.8%

25-34 3,848 19.4 2,995 77.8 2,563 66.6 2,093 54.4 69.9%

35-44 4,757 24.0 3,655 76.8 3,335 70.1 2,928 61.6 80.1%

45-54 6,191 31.3 5,045 81.5 4,740 76.6 4,232 68.4 83.9%

55+ 4,039 20.4 3,206 79.4 3,059 75.7 2,833 70.1 88.4%

Mode of Transmission

MSM 13,432 67.9 10,792 80.3 9,874 73.5 8,790 65.4 81.4%

IDU 1,375 6.9 1,041 75.7 939 68.3 789 57.4 75.8%

MSM/IDU 809 4.1 651 80.5 591 73.1 472 58.3 72.5%

Heterosexual 4,024 20.3 3,062 76.1 2,770 68.8 2,400 59.6 78.4%

Pediatric 131 0.7 102 77.9 93 71.0 69 52.7 67.6%

Adult Other 22 0.1 16 72.7 15 68.2 12 54.5 75.0%

Table 3.24

HIV Care Continuum by Gender, Race/Ethnicity, Age, Transmission Mode Dallas HSDA

2015

PLWH At Least One

Visit Retained in Care Suppressed

% Suppressed of those Retained

# % # # % # % %

All PLWH 19,768 100.0 15,641 79.1 14,260 72.1 12,513 63.3 87.7%

Gender

(F)Female 3,928 19.9 3,049 77.6 2,753 70.1 2,362 60.1 85.8%

(M)Male 15,840 80.1 12,592 79.5 11,507 72.6 10,151 64.1 88.2%

Race/Ethnicity

White Non-Hispanic 6,192 31.3 5,158 83.3 4,860 78.5 4,455 71.9 91.7%

Black Non-Hispanic 8,202 41.5 6,268 76.4 5,512 67.2 4,610 56.2 83.6%

Hispanic 4,375 22.1 3,369 77.0 3,113 71.2 2,774 63.4 89.1%

All Other/Unknown 999 5.1 846 84.7 775 77.6 674 67.5 87.0%

Age

< 24 956 4.8 762 80.3 583 61.0 448 46.9 76.8%

25 - 44 8,609 43.6 6,654 77.3 5,902 68.6 5,023 58.3 85.1%

> 44 10,203 51.6 8,225 80.6 7,775 76.2 7,042 69.0 90.6%

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PLWH At Least One

Visit Retained in Care Suppressed

% Suppressed of those Retained

# % # # % # % %

Mode of Transmission

MSM 13,398 67.8 10,765 80.3 9,849 73.5 8,770 65.5 89.0%

IDU or MSM/IDU 2,180 11.0 1,686 77.3 1,522 69.8 1,254 57.5 82.4%

Heterosexual 4,038 20.4 3,072 76.1 2,781 68.9 2,407 59.6 86.6%

All Other 153 0.8 118 77.1 108 70.6 81 52.9 75.0%

Table 3.25

HIV Care Continuum by Gender, Race/Ethnicity, Age, Transmission Mode Sherman-Denison HSDA

2015

PLWH At Least One

Visit Retained in

Care Suppressed

% Suppressed of those Retained

# % # % # % # % %

All PLWH 226 100.0 189 83.6 179 79.2 154 68.1 86.0%

Gender

(F)Female 48 21.2 37 77.1 36 75.0 31 64.6 86.1%

(M)Male 178 78.8 152 85.4 143 81.5 123 69.1 86.0%

Race/Ethnicity

White Non-Hispanic 146 64.6 123 84.2 119 81.5 103 70.5 86.6%

Black Non-Hispanic 41 18.1 33 80.5 28 68.3 20 48.8 71.4%

Hispanic 23 10.2 19 82.6 18 78.3 17 73.9 94.4%

All Other/Unknown 16 7.1 14 87.5 14 87.5 14 87.5 100.0%

Age

< 24 10 4.4 10 100.0 8 80.0 7 70.0 87.5%

25 - 44 86 38.1 70 81.4 67 77.9 57 66.3 85.1%

> 44 130 57.5 109 83.8 104 80.0 90 69.2 86.5%

Mode of Transmission

MSM 117 51.8 103 88.0 97 82.9 84 71.8 86.6%

IDU or MSM/IDU 54 23.9 41 75.9 39 72.2 31 57.4 79.5%

Heterosexual 51 22.6 43 84.3 41 80.4 37 72.5 90.2%

All Other 4 2.0 2 50.0 2 50.0 2 50.0 100.0%

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LINKAGE TO CARE Linkage to care is measured by the first medical visit following a positive test result during the measurement year (2015). Episodes are measured in one month or less, two to three months, four to twelve months and not linkage reported. A majority of PLWH in the Dallas EMA, the Dallas HSDA, and the Sherman-Denison HSDA were linked to care within one month.

 86.7% of PLWH in Sherman-Denison were linked to care within one month, and the rest were linked within two to three months.

 In the Dallas EMA and Dallas HSDA, just over 64% of PLWH were linked within one month. 16.8% were linked to care within two to three months, and nearly 8% were linked in four to twelve months.

 Slightly over 11% of PLWH in the Dallas EMA and Dallas HSDA were not linked to care in 2015.

Table 3.26 Linkage to Care 2015

Within 1 month Two to three months Four to 12 months Not Linked

# % # % # % # %

Dallas EMA 622 64.5% 162 16.8% 74 7.7% 107 11.1%

Dallas HSDA 620 64.2% 162 16.8% 75 7.8% 108 11.2%

Sherman- Denison

13 86.7% 2 13.3% 0 0.0% 0 0.0%

Figure 3.11

Linked in 1 month, 622,

64%

Linked in 2-3 months, 162,

17%

Linked in 4-12 months, 74,

8% Not Linked, 107, 11%

Linkage to Care 2015 Dallas EMA

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Figure 3.12

Figure 3.13

1, 620, 64%

2, 162, 17%

3, 75, 8%

4, 108, 11%

Linkage to Care 2015 Dallas HSDA

Linked in 1 month, 13,

87%

Linked in 2-3 months, 2, 13%

Linked in 4-12 months, 0, 0%

Not Linked, 0, 0%

Linkage to Care, Sherman-Denison HSDA 2015

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RETENTION IN CARE In 2015, TDSHS introduced a Healthier Community initiative to further examine retention in care and to establish goals to achieve retention and viral suppression. Fact sheets developed for the Dallas and Sherman-Denison HSDAs depicting the impact of HIV care and treatment for PLWH in these jurisdictions are contained in Appendix 3.1 as well as Figure 3.14 below.

 In the Dallas EMA and Dallas HSDA, 79% of PLWH were linked to care (one or more episodes of treatment in the calendar year) in 2015 and 72% were retained in care (two or more episodes of treatment in the calendar year). Of those linked in care, 63% were virally suppressed. Of those retained in care, 88% were virally suppressed.

 In the Sherman-Denison HSDA, 84% were linked to care in 2015 and 79% were retained in care. Of those linked to care, 68% were virally suppressed, and of those retained in care, 86% were virally suppressed.

TDSHS established targets for the region at 85% of PLWH who would be retained in care and 81% of those retained would be virally suppressed.

 With an 85% retention rate, TDSHS projects 2,543 additional PLWH from the Dallas EMA or HSDA would be retained in care. At 81% suppression, 1,094 in the Dallas EMA and 1,097 additional PLWH in the Dallas HSDA would be achieve viral suppression.

 Using the same targets, 13 additional PLWH from Sherman-Denison HSDA would be retained in care, and two additional would achieve viral suppression.

Table 3.27

Retention and Viral Suppression Targets

PLWH Retained in Care

85% Retained

Goal Gap Suppressed

81% Suppressed

Goal Gap

# % # % # # # # #

Dallas EMA 19,793 100 14,281 72.2% 16,824 2,543 12,533 13,627 1,094

Dallas HSDA 19,768 100 14,260 72.1% 16,803 2,543 12,513 13,610 1,097

Sherman- Denison HSDA

226 100 179 79.2% 192 13 154 156 2

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Figure 3.14 Healthier Community

A. DALLAS HSDA

B. SHERMAN-DENISON HSDA

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MEASURES OF VIRAL LOAD Sustained viral load suppression is the ultimate outcome for HIV treatment. Measuring suppression consists of four indicators: population viral load, community viral load, in-care viral load and monitored viral load. Definitions formulated by the CDC are as follows:2

 Population Viral Load includes viral loads of all HIV-infected persons in the population, both those unaware of their HIV status (undiagnosed) and those who are aware of their HIV status (diagnosed), whether or not linked and retained in HIV care. An estimated 18% to 21% of HIV- infected Americans are living with undiagnosed HIV infection and, their HIV viral loads are unknown but are likely detectable and elevated in the absence of antiretroviral therapy.

 Community Viral Load describes viral load of all HIV-infected persons diagnosed with HIV infection in a given population.

 In-Care Viral Load includes both the HIV viral loads of PLWH who have accessed the healthcare system, been diagnosed with HIV infection, and have viral load testing results reported to HIV surveillance.

 Monitored Viral Load is limited to the HIV viral loads of PLWH who have been diagnosed with HIV infection, who are receiving medical care and disease monitoring through viral load testing, and whose results are reported to HIV surveillance. This measure excludes persons that may be in care, but do not have viral load data available due to incomplete reporting or less frequent monitoring.

The viral load measures were calculated by TSDH for the State of Texas, the Austin TGA and Dallas EMA by TSDH. Results for Dallas EMA are shown in Table 3.27. It demonstrates that in-care and monitored PLWH achieve viral suppression to a greater extent than those measured by population or community viral loads. It also shows that approximately half of those with HIV in the Dallas EMA, either aware or unaware but not in care, are not virally suppressed.

 In the Dallas EMA general population, of the 23,933 with HIV who know or do not know their status, i.e. Aware and Unaware, 52.5% are known to be virally suppressed.

 In the Dallas EMA, of those who are aware of their HIV status, 63.3% are known to be virally suppressed.

 Of PLWH with at least one medical visit, 80.0% were virally suppressed in 2015.

 Of those who received at least one viral load test in 2015, 81.7 were virally suppressed in 2015.

2 Source: CDC (August 2011), Guidance on Community Viral Load: A Family of Measures, Definitions, and Method

for Calculation.

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Table 3.28 MEASURES OF VIRAL LOAD

Dallas EMA 2015

Dallas EMA

No. of PLWH who know and do not know their HIV Status 23,933

No. of PLWH who know their status (at end of 2015) 19,793

No. of PLWH who had a Met Need in 2015 15,664

No. of PLWH with >= 1 VL test in 2015 15,333

No. of PLWH who were virally suppressed (<= 200 copies/mL) at end of 2015 12,533

% of PLWH with a suppressed viral load out of PLWH who know and do not know their status - Population Viral Load

52.4%

% of PLWH with a suppressed viral load out of PLWH who know their status (at the end of 2015) - Community Viral Load

63.3%

% of PLWH with a suppressed viral load out of PLWH who had a Met Need in 2015 - In- Care Viral Load

80.0%

% of PLWH with a suppressed viral load out of PLWH with >= 1 VL test in 2015 - Monitored Viral Load

81.7%

Figure 3.15

52.4%

63.3%

80.0% 81.7%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Population Viral Load Community Viral Load

In-Care Viral Load Monitored Viral Load

Measures of Viral Load Dallas EMA

2015

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RYAN WHITE HIV/AIDS PROGRAM CLIENT IN-CARE PROFILE Data reported in the following section were obtained from the 2016 ARIES Statistical Analysis Report. They reflect Ryan White HIV/AIDS Program (RWHAP) clients from the Super Dallas/Sherman provider sites. Super Dallas/Sherman refers to the aggregate of the Dallas and Sherman-Denison HSDAs. In 2016, there were 9,609 PLWH enrolled in Super Dallas/Sherman RWHAP.

 Of the total number of clients served, 14.9% were new clients in 2016.

 Most clients reside in the Dallas HSDA (93.2%) or Sherman-Denison HSDA (1.6%); 5.1% of clients from outside the Dallas and Sherman-Denison HSDA’s consumed services.

 21 clients (<1%) died in 2016.

Table 3.29 ARIES Statistical Analysis Report - Overview

Super Dallas/Sherman (Aggregating Administered Agencies) Period: 1/1/2016 to 12/31/2016

ARIES Report Summary 2016

# %

Unduplicated number of clients served 9,609 100.0%

Unduplicated number of new clients served 1,427 14.9%

Clients served who died during reporting period 21 0.2%

Clients from Dallas HSDA 8,958 93.2%

Clients from Sherman-Denison HSDA 156 1.6%

Clients outside Dallas/Sherman-Denison HSDA 495 5.1%

HIV/AIDS Disease Status Among RWHAP clients, the majority had been diagnosed as HIV-positive (63.0%).

 There was an underrepresentation of clients with AIDS in RWHAP client base in 2016 when compared to the overall disease status of those in the Dallas EMA. In the Dallas EMA, 51.8% of PLWH had AIDS and 48.2% were HIV-positive in 2015.

Table 3.30

RWHAP Clients by Disease Status Super Dallas/Sherman

2016

HIV/AIDS Status 2016

# %

HIV-negative 55 0.0%

HIV-positive 6,058 63.0%

AIDS 3,378 35.2%

Unreported/Unknown 118 0.0%

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Gender

 In 2016, more than 75% of RWHAP clients were male (77.0%).

 Women comprised 22% of the total clients, while transgender male-to-female accounted for less than 1% of all clients.

 The proportion of women in-care and using RWHAP services (22%) was slightly higher than the proportion of all female PLWH in Dallas EMA (19.8%).

 Among all PLWH in the Dallas EMA in 2015, 80% were male and 20% female.

Table 3.31 RWHAP Clients by Gender

Super Dallas/Sherman 2016

Gender 2016

# %

Male 7,394 77.0%

Female 2,146 22.3%

Transgender MTF 69 0.7%

Unknown 0 0.00%

Race/Ethnicity

 The majority of RWHAP clients were Black/African-American (49%), followed by White/Caucasian (25%), and Hispanic (24%).

 The racial/ethnic profile of PLWH in the Dallas EMA closely resembled the profile for RWHAP clients. Of the total PLWH in the Dallas EMA in 2015, 41% were Black/African American, 32% White/Caucasian, and 22% were Hispanic/Latino.

Table 3.32 RWHAP Clients by Race/Ethnicity

Super Dallas/Sherman 2016

Race/Ethnicity 2016

# %

White 2,438 25.4%

Black 4,698 48.9%

Hispanic 2,292 23.9%

Asian 109 1.1%

Native Hawaiian/Pacific Islander 14 0.1%

American Indian or Alaskan Native 28 0.3%

Unknown 27 0.3%

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Age

 In 2016, 95% of RWHAP clients were age 25 or older. This was reflective of the ages of PLWH in the Dallas EMA. In 2015, 95% of total PLWH in the Dallas EMA were age 25 or older.

Table 3.332

PWHAP Clients by Age Super Dallas/Sherman

2016

Age Group 2016

# %

<2 9 0.1%

2-12 41 0.4%

13-24 395 4.1%

25-44 4,371 45.5%

45-64 4,435 46.2%

65+ 355 3.7%

Exposure – Transmission Mode

 Male sex with men (MSM) was the highest represented mode of transmission reported by RWHAP clients in 2016.

 55.9% of clients were MSM, while heterosexual contact (31.5%) was the second largest group.

 In 2015, the Dallas EMA MSM population accounted for 67.9% of PLWH and heterosexual contact accounted for 20.3% of PLWH.

 MSM represent a smaller share of RWHAP clients (55.9%) than for overall PLWH (67.9%) in the Dallas EMA. This could be a result of higher percentage of unknown/other (5.9%) among clients, compared to just 0.1% for PLWH in the Dallas EMA.

Table 3.34 RWHAP Clients by Mode of Transmission

Super Dallas/Sherman 2016

Transmission Mode 2016

# %

MSM 5,369 55.9%

IDU 315 3.3%

MSM & IDU 248 2.6%

Heterosexual Contact 3,031 31.5%

Blood transfusion, blood component, or tissue /Hemophilia, coagulation disorder 64 0.7%

Perinatal 14 0.1%

Unknown/Other 568 5.9%

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Living Status

 Over half (55%) of clients reported having a stable or permanent living situation in 2016, while 40% had temporary housing, and 3% lived in unstable housing.

 Of those clients in a stable housing situation, nearly half resided in rental units (46%).

 Over one-third (36%) of RWHAP in a temporary living situation in 2016 were living with relatives or friends.

 The majority of clients in an unstable living condition were homeless from the streets (2% of all RWHAP clients).

Table 3.35 RWHAP Clients by Living Situation

Super Dallas/Sherman 2016

Living Situation 2016

# %

Stable/Permanent 5,286 55.0%

Board care or assisted living 26 0.3%

Participant-owned housing 806 8.4%

Rental housing 4,208 43.8%

Rented room 246 2.6%

Temporary 3,874 40.3%

Hospital or other medical facility 24 0.3%

Jail/Prison 45 0.5%

Living with relatives/friends 3,510 36.5%

Psychiatric facility 3 0.0%

Substance abuse treatment facility 86 0.9%

Transitional housing 206 2.1%

Unstable 323 3.4%

Homeless from emergency shelter 102 1.0%

Homeless from the streets 221 2.3%

Unknown 123 1.3%

Other 46 0.5%

Refused to answer 0 0.0%

Unknown 32 0.3%

Insurance Status

 Nearly half (47%) of RWHAP clients reported having no insurance. The majority of those insured relied on public plans.

 Medicaid beneficiaries represented 15% of RWHAP clients, while Medicare beneficiaries represented 16%.

 18% of RWHAP clients relied on other public insurance, other than Medicare and Medicaid, for coverage.

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 Only 6% of clients had private insurance coverage, and another 38% reported unknown insurance status.

Table 3.36

RWHAP Clients by Insurance Type Super Dallas/Sherman

2016

Insurance Type 2016

# %*

Private 550 5.7%

Medicare 1,585 16.5%

Medicaid 1,460 15.2%

Other public 1,714 17.8%

No insurance 4,543 47.3%

Other 234 2.4%

Unknown 3,698 38.5% *Sum of percents may exceed 100% because clients may have more than one insurance type.

CD4 Test and Viral Load Test

 The majority of RWHAP clients had an undetectable viral load off less than 50 copies per mL. Furthermore, the majority of clients had a CD4 count that exceeded 200 cells per mm.

 Excluding the 16% of clients that did not undergo tests for viral load during this reporting period, 56% were undetectable below 50 and 10% had a viral load count between 50 and 500.

 13% of clients had a CD4 count below 200, which is an indication of disease progression.

Table 3.37 RWHAP Clients by CD4 Count and Viral Load Count

Super Dallas/Sherman 2016

CD4 & Viral Load Count 2016

CD4 Count # %

0-49 267 2.8%

50-99 286 3.0%

100-199 675 7.0%

200-349 1,467 15.3%

350-499 1,743 18.1%

500-749 2,312 24.1%

750 and above 1,595 16.6%

No CD4 test within the reporting period 1,261 13.1%

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CD4 & Viral Load Count 2016

Viral Load Count # %

0-50 5,340 55.6%

51-100 405 4.2%

101-500 528 5.5%

501-10,000 580 6.0%

10,001-50,000 550 5.7%

50,001-100,000 252 2.6%

100,001-500,000 300 3.1%

500,001 and above 79 0.8%

No viral load test within the reporting period 1,572 16.4%

Service Summary – RSR Category Among 19 RWHAP service categories, approximately half of RWPHA clients used several of the services available, including non-medical case management (52%), outpatient/ambulatory medical care (46%), and medical case management (44%).

 Nearly one-quarter (24%) of clients used food bank/home-delivered meals. This service is the most used if case management and ambulatory care are excluded.

 The number of RWHAP clients using housing services was 118, which is only 36% of the number of clients with an unstable living condition (323).

 Medical transport (19%), local AIDS pharmaceutical assistance (16%), oral health (13%), and outreach (12%) were all services used by more than 10% of RWHAP clients.

Table 3.38

RWHAP Clients by Service Category Super Dallas/Sherman

2016

Service Category 2016

# %

AIDS Pharmaceutical Assistance (local) 1,533 16.0%

Case Management (non-medical) 5,037 52.4%

Child Care Services 19 0.2%

Early Intervention Services 161 1.7%

Food Bank/Home-Delivered Meals 2,283 23.8%

Health Insurance Premium and Cost Sharing Assistance 465 4.8%

Housing Services 118 1.2%

Housing Subsidy Assistance 32 0.3%

Legal Services 181 1.9%

Linguistic Services 126 1.3%

Medical Case Management (including Treatment Adherence) 4,199 43.7%

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Service Category 2016

# %

Medical Transportation Services 1,818 18.9%

Mental Health Services 307 3.2%

Oral Health Care 1,284 13.4%

Outpatient/Ambulatory Medical Care 4,430 46.1%

Outreach Services 1,178 12.3%

Respite Care 143 1.5%

Substance Abuse Services - Outpatient 92 1.0%

Supportive Services 7 0.1%

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4. CHARACTERISTICS OF THE POPULATION AND PRIORITY POPULATIONS Combining data from all primary and secondary research study components (epi profile, demographic profile, key informant interviews, focus groups, and consumer surveys), this section analyzes the total sample of in-care and out-of-care consumers. Also presented are a comparison of priority populations including:

 Black/African-American Men and Women

 Hispanic/Latino Men and Women

 Men who have Sex with Men (MSM)

 Transgender Persons

 Youth (age 13-24) Each priority population analysis includes:

 Population definition.

 Sample size, including both in-care and out-of-care consumers.

 Demographics.

 Barriers to care, for both in-care and out-of-care PLWH.

 Focus group results.

 Top 10 ranked service needs and unfulfilled needs for the total sample, in-care and out-of-care, if sample size allows.

 Total need includes the services that are currently being used and services that are not being used but are identified as needed.

 Unfulfilled need identifies services that consumers report as needed but they are not using.

 Other survey questions specifically related to that population.

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TOTAL SAMPLE IN CARE AND OUT-OF-CARE SURVEY SAMPLE The consumer survey sample was comprised of 697 people living with HIV/AIDS (PLWH). This included 457 (66%) in-care consumers and 240 (34%) out-of-care/returned to care. Total survey sample, in-care and out-of-care consumers are presented first followed by priority populations, in alphabetical order. Survey results are presented for total sample, in-care and out-of-care responses. RESPONDENT OVERVIEW Survey respondents conformed to the overall epidemic in the areas of gender and age. 1

 Gender of the survey sample was very close to that of that found in the population using services. The survey sample included 75% male respondents, 23% female, and 2% Transgender. This compares to 80% males and 20% females infected in the region. No Transgender individuals were reflected in the data on the epidemic; however, when adjusting for transgender, 2% of the sample compares to 1% of those receiving services.

 The age profile of respondents showed they were slightly older than those reflected in the regional epidemic.

Demographics The consumer survey sample is similar to the epidemic in the Dallas region. The survey sample includes 75% male, 23% female, and 2% Transgender. The epidemiologic data includes 80% male and 20% female. Transgender individuals are not reported in the epidemiologic data.

 In-care and out-of-care respondents were consistent with the total sample with regard to gender.

Table 4.1 Gender

In-Care Out-of-Care Total EPI Profile

Gender Identity # % # % # % %

Male 343 75.1% 180 75.0% 523 75.0% 80.2%

Female 104 22.8% 55 22.9% 159 22.8% 19.8%

Transgender / Other Gender Identity 10 2.2% 5 2.1% 15 2.2% N/A

Total 457 100.0% 240 100.0% 697 100.0% 100.0%

In-Care n = 457; Out-of-Care n = 240; Combined In-Care n = 697

1 For the respondent overview, epidemiology data were obtained from Texas DSHS HIV Surveillance 2015 eHARS,

and RWHAP data from ARIES STAR Report, January 1, 2016 through December 31, 2016

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By race, Whites/Caucasians and Hispanics were under-sampled on the consumer survey relative to their presence in the regional epidemic, and Black/African-Americans were over-sampled.

 Whites comprise 32% of the regional epidemic and 25% of the survey sample. Whites comprised 25% of in-care respondents and 24% of those out-of-care.

 Hispanics/Latinos, represented 22% of the regional epidemic, were 16% of the sample including 17% of in-care and 15% of out-of-care respondents.

 Black/African-Americans were 56% of the sample and are 41% of the regional epidemic, including 55.4% of in-care and 55.8% of out-of-care respondents.

Table 4.2

Race/Ethnicity

In-Care Out-of-Care Total EPI Profile

Race/Ethnicity # % # % # % %

Black/African-American 253 55.4% 134 55.8% 387 55.5% 41.30%

White/Caucasian 114 24.9% 58 24.2% 172 24.7% 31.60%

Hispanic/Latino (of any Race) 76 16.6% 37 15.4% 113 16.2% 22.10%

Multi-Racial 5 1.1% 9 3.8% 14 2.0% N/A

Native American 2 0.4% 1 0.4% 3 0.4% N/A

Asian 3 0.7% 0 0.0% 3 0.4% N/A

Other Race/Ethnicity 4 0.9% 1 0.4% 5 0.7% 1.20%

Total 457 100.0% 240 100.0% 697 100.0% 96.2%*

In-Care n = 457; Out-of-Care n = 240; Combined In-Care n = 697 **Percentage does not sum to 100% because PLWH cases labeled unknown race/ethnicity are not included.

 Considering age of respondents, the sample was older than the those found in the regional epidemic.

 Approximately 3% of PLWH were in the 13 to 24 age range; 13 to 24 year-olds are 5% of the epidemic.

 16% of respondents were in the 25 to 34 age group compared to this age cohort being 19% of the epidemic.

 20% of respondents were in the 35 to 44 age group compared to this age cohort being 24% of the epidemic.

 30% of respondents were in the 45 to 54 age group compared to this age cohort being 31% of the epidemic.

 28% of respondents were in the 55 and older age group compared to this age cohort being 20% of the epidemic.

 The regional epidemic included 20% of the PLWH who are 55 and older, and 28% of the sample is in this age range.

 Out-of-care survey respondents tended to be younger than those in-care.  The 13 to 24 age group comprised 2% of in-care respondents, and 6% of out-of-care.  The 25 to 34 age group included 13% of those in-care and 23% of out-of-care.

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 The 35-44 age group included 19% in-care and 23% of the out-of-care.  The 45 to 54 age group included 30% of the in-care, and 30% of out-of-care.  The 55+ age group included 34% in-care and 16% of those out-of-care.

Table 4.3

Age

In-Care Out-of-Care Total EPI Profile

Age Cohort # % # % # % %

Age 13-24 7 1.5% 15 6.3% 22 3.2% 4.9%

Age 25-34 59 12.9% 54 22.5% 113 16.2% 19.4%

Age 35-44 85 18.6% 54 22.5% 139 19.9% 24.0%

Age 45-54 139 30.4% 73 30.4% 212 30.4% 31.3%

Age 55+ 157 34.4% 39 16.3% 196 28.1% 20.4%

Age Not Reported 10 2.2% 5 2.1% 15 2.2% N/A

Total 457 100.0% 240 100.0% 697 100.0% 100.0%

In-Care n = 457; Out-of-Care n = 240; Combined In-Care n = 697

County of Residence Eighty-three percent of the survey sample resided in Dallas County, which is comparable to the Dallas County percentage in the regional epidemic (82%).

 82% of in-care respondents were from Dallas.

 In the rural/suburban counties, Denton (10%), Collin (3%) and Grayson (3%) had the number and highest percentage of survey respondents.

 Denton County residents comprised 10% of the sample and 6% of the regional epidemic.  Collin County had the second highest percent of respondents at 3% compared to 8% of

those diagnosed.  Grayson County residents were <1% of the regional epidemic but comprised 3% of the

sample.

Table 4.4 County of Residence

In-Care Out-of-Care Total EPI Profile

County # % # % # % %

Collin 17 3.7% 7 2.9% 24 3.4% 7.7%

Cooke 3 0.7% 0 0.0% 3 0.4% 0.1%

Dallas 375 82.1% 204 85.0% 579 83.1% 81.5%

Denton 45 9.8% 21 8.8% 66 9.5% 5.8%

Ellis 0 0.0% 1 0.4% 1 0.1% 1.2%

Fannin 1 0.2% 0 0.0% 1 0.1% 0.1%

Grayson 15 3.3% 7 2.9% 22 3.2% 0.9%

Henderson 0 0.0% 0 0.0% 0 0.0% 0.5%

Hunt 1 0.2% 0 0.0% 1 0.1% 0.5%

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In-Care Out-of-Care Total EPI Profile

County # % # % # % %

Kaufman 0 0.0% 0 0.0% 0 0.0% 0.9%

Navarro 0 0.0% 0 0.0% 0 0.0% 0.4%

Rockwall 0 0.0% 0 0.0% 0 0.0% 0.4%

Total 457 100.0% 240 100.0% 697 100.0% 100.0%

In-Care n = 457; Out-of-Care n = 240; Combined In-Care n = 697

Transmission Mode The consumer survey allowed the selection of multiple transmission modes. The most frequently identified included men having sex with men (50%), heterosexual contact (32%), IDU (6%), and Other (9%). Texas DSHS surveillance data identified the following single risk categories for PLWH in the Dallas EMA and Sherman-Denison HSDA: MSM (68%), heterosexual transmission (20%), IDU (7%), IDU+MSM (4%), Other (0.1%).

 In-care consumers were less likely to identify as MSM when compared to out-of-care, with 47% of in-care compared to 55% of out-of-care identifying this mode.

 More in-care consumers (35%) identified heterosexual transmission than those in-care (25%).

Table 4.5 Transmission Mode

In-Care Out-of-Care Total EPI Profile

Transmission Mode # % # % # % %

MSM 216 47.3% 133 55.4% 349 50.1% 67.9%

IDU 26 5.7% 16 6.7% 42 6.0% 6.9%

MSM + IDU 11 2.4% 6 2.5% 17 2.4% 4.1%

Heterosexual 161 35.2% 61 25.4% 222 31.9% 20.3%

Do Not Know 32 7.0% 23 9.6% 55 7.9% 0.7%

Other 45 9.8% 22 9.2% 67 9.6% 0.1%

In-Care n = 457; Out-of-Care n = 240; Combined In-Care n = 697. Respondents were permitted to choose more than one.

Educational Attainment and Employment Respondents’ educational attainment varied, with those not completing high school (16%), high school graduates (35%) and college attendance/graduate level (40%).

 Slight differences exist between in-care and out-of-care consumers’ educational attainment.  16% of in-care participants compared to 17% of out-of-care did not complete high school.  36% of in-care and 33% of out-of-care were high school graduates.  44% of in-care and 43% of out-of-care attended some college through graduate level.

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Table 4.6 Educational Attainment

In-Care Out-of-Care Total

Educational Attainment # % # % # %

Eighth Grade or Less 17 3.7% 6 2.5% 23 3.3%

Some High School 56 12.3% 34 14.2% 90 12.9%

High School Graduate/GED 164 35.9% 79 32.9% 243 34.9%

Technical or Trade School 19 4.2% 15 6.3% 34 4.9%

Some College 130 28.4% 71 29.6% 201 28.8%

Completed College 49 10.7% 23 9.6% 72 10.3%

Graduate Education 20 4.4% 8 3.3% 28 4.0%

Other 2 0.4% 4 1.7% 6 0.9%

Total 457 100.0% 240 100.0% 697 100.0%

In-Care n = 457; Out-of-Care n = 240; Combined In-Care n = 697

Only a small percent of survey respondents reported military service (6%), with 7% of those in-care and 4% of those out-of-care.

Table 4.7 Military Service

In-Care Out-of-Care Total

Served in Military # % # % # %

Yes 32 7.0% 9 3.8% 41 5.9%

No 423 92.6% 229 95.4% 652 93.5%

Do Not Want To Say 2 0.4% 2 0.8% 4 0.6%

Total 457 100.0% 240 100.0% 697 100.0%

In-Care n = 457; Out-of-Care n = 240; Combined In-Care n = 697

Seventy-six percent of the sample were unemployed, compared to 62% in 2007, 72% in 2010, and 80% in 2013.

 13% were working full time and 11% working part time.

 78% of in-care respondents and 71% of out-of-care respondents were unemployed.

 15% of out-of-care held full-time jobs, and 14% had a part-time job.

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Table 4.8 Employment Status

In-Care Out-of-Care Total

Employment Status # % # % # %

Work Full-Time 58 12.7% 35 14.6% 93 13.3%

Work Part-Time 44 9.6% 33 13.8% 77 11.0%

Not Working 355 77.7% 172 71.7% 527 75.6%

Total 457 100.0% 240 100.0% 697 100.0%

In-Care n = 457; Out-of-Care n = 240; Combined In-Care n = 697

Of the 527 survey respondents who were not currently working, nearly half of in-care respondents were on disability compared to 35% of those out-of-care.

 An additional 14% of in-care respondents said their health keeps them from working compared to 17% of those out-of-care.

 23% of those not working were looking for work. This included 19% of in-care and 31% of out-of- care consumers.

Table 4.9

Unemployed Status

Although incomes were generally low for all respondents, out-of-care reported larger percentages earning less than $950 per month.

 74% of out-of-care consumers earned incomes less than $950 per month compared to 65% of in- care consumers.

In-Care Out-of-Care Total

If You Are Not Working, Which Best Describes You? # % # % # %

I am a student 11 3.1% 7 4.1% 18 3.4%

I am looking for a job 67 18.9% 54 31.4% 121 23.0%

I am retired 23 6.5% 2 1.2% 25 4.7%

I work as a volunteer 11 3.1% 6 3.5% 17 3.2%

My health keeps me from working - I am not on disability

49 13.8% 29 16.9% 78 14.8%

My health keeps me from working - I am on disability 176 49.6% 60 34.9% 236 44.8%

Other 18 5.1% 14 8.1% 32 6.1%

Total 355 100.0% 172 100.0% 527 100.0%

In-Care n = 355; Out-of-Care n = 172; Combined In-Care n = 527

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Table 4.10 Income

In-Care Out-of-Care Total

Monthly Income # % # % # %

Less than $950 298 65.2% 177 73.8% 475 68.1%

$950 - $1,900 112 24.5% 45 18.8% 157 22.5%

$1,901 - $2,800 35 7.7% 12 5.0% 47 6.7%

More than $2,800 12 2.6% 6 2.5% 18 2.6%

Total 457 100.0% 240 100.0% 697 100.0%

In-Care n = 457; Out-of-Care n = 240; Combined In-Care n = 697

Substance Use and Mental Health Diagnoses The consumer survey asked about current drug and alcohol use, with the following results:

 The total sample included 3% injecting drug users, with 2% of these consumers being in-care and over 6% being out-of-care.

 The sample also included 60% who “gave no response,” with 62% of these consumers in-care and 58% out-of-care consumers.

Consumers asked about drug use in the last six months responded as follows:

 51% of in-care consumers responded “Yes”, 48% responded “No”, and 1.6% did not respond.

 65% of out-of-care consumers responded “Yes” to using drugs in the last six months.

Table 4.11 Substance Use

In-Care Out-of-Care Total

Substance Use # % # % # %

Have Used Drugs or Alcohol in Past 6 Months 237 51.9% 155 64.6% 392 56.2%

No Drugs Listed Used 220 48.1% 85 35.4% 305 43.8%

Total 457 100.0% 240 100.0% 697 100.0%

In-Care Out-of-Care Total

IV Drug Use – Injected in the last two months # % # % # %

Yes 8 1.8% 15 6.3% 23 3.3%

No 168 36.8% 85 35.4% 253 36.3%

No Response 281 61.5% 140 58.3% 421 60.4%

Total 457 100.0% 240 100.0% 697 100.0%

In-Care n = 457; Out-of-Care n = 240; Combined In-Care n = 697

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 The most frequent substance used in the last six months was alcohol (69%) followed by marijuana (46%). These were also the most frequently used substances by both in-care and out-of-care.

 A higher percentage out-of-care substance users used marijuana (56%) compared to in- care (41%).

 Out-of-care substance users used alcohol (74%) compared to in-care (66%).

 Stimulants were the third most frequently used substance, with 20% of the survey sample identifying this drug category; This includes 27% of those out-of-care and 16% of in-care respondents.

 Opioids/morphine was used by 10% of out-of-care substance users and 12% of in-care.

 Depressants were identified by 10% of substance users, including 13% of in-care and 7% of out- of-care.

Table 4.12

Substances Used in the Last 6 Months

In-Care Out-of-Care Total

Substance Use # % # % # %

Alcohol 157 66.2% 114 73.5% 271 69.1%

Marijuana 96 40.5% 86 55.5% 182 46.4%

Depressants 30 12.7% 10 6.5% 40 10.2%

Ketamine/PCP 0 0.0% 1 0.6% 1 0.3%

Hallucinogens 2 0.8% 2 1.3% 4 1.0%

Opioids and Morphine 28 11.8% 16 10.3% 44 11.2%

Stimulants 37 15.6% 41 26.5% 78 19.9%

Steroids not prescribed by your doctor 3 1.3% 0 0.0% 3 0.8%

Prescription painkillers not prescribed by your doctor 17 7.2% 7 4.5% 24 6.1%

Inhalants 4 1.7% 6 3.9% 10 2.6%

In-Care n = 237; Out-of-Care n = 155; Combined In-Care n = 392

Respondents who indicated alcohol use were asked if they used alcohol more than 3 times a week.

 Overall, out-of-care consumers were more likely to use alcohol more than 3 times a week (37%) than those who were in-care (29%).

Table 4.13

Do You Drink Alcohol More Than 3 Times A Week?

In-Care Out-of-Care Total

Do you Drink Alcohol More Than 3 Times A Week? # % # % # %

Yes 37 23.6% 42 36.8% 79 29.2%

No 120 76.4% 72 63.2% 192 70.8%

Total 157 100.0% 114 100.0% 271 100.0%

In-Care n = 157; Out-of-Care n = 114; Combined In-Care n = 271

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Active substance users were asked if they had “thought about going to substance abuse treatment.”

 28% responded positively, and 72% negatively.

 More in-care respondents had not thought of getting treatment (78%) than those out-of-care (60%).

Table 4.14 Considering Treatment

In-Care Out-of-Care Total

Have You Thought About Seeking Substance Abuse Treatment? # % # % # %

Yes 51 21.5% 59 38.1% 110 28.4%

No 184 77.6% 93 60.0% 277 71.6%

No Response 2 0.8% 3 1.9% 5 1.3%

Total 237 100.0% 155 100.0% 387 100.0%

In-Care n = 237; Out-of-Care n = 155; Combined In-Care n = 387

Almost one-third of consumer survey respondents have been diagnosed with depression.

 A slightly higher percentage of in-care consumers reported depression (31%) than those out-of- care/returned to care (27%).

 73% of the out-of-care and 69% of in-care respondents report no depression.

Table 4.15 Depression Diagnosis

In-Care Out-of-Care Total

Have You Received Medical Treatment for Depression in the Last 12 Months? # % # % # %

Yes 143 31.3% 64 26.7% 207 29.7%

No 314 68.7% 176 73.3% 490 70.3%

Total 457 100.0% 240 100.0% 697 100.0%

In-Care n = 457; Out-of-Care n = 240; Combined In-Care n = 697

DIAGNOSIS AND REFERRAL FOR CARE Slight differences existed between diagnosis dates of in-care and out-of-care consumers with out-of-care being more recently diagnosed.

 More than 57% of out-of-care were diagnosed since 2005. This compared to nearly 41% of those in-care.

 21% of in-care consumers were diagnosed in the last five years. This compared to 35% of out-of-care/returned to care consumers.

 Over 11% of in-care were diagnosed between 2014 and 2017, compared to 19% of out- of-care/returned to care.

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 More than 43% of out-of-care consumers were diagnosed before 2005, compared to 58% in-care consumers.

Table 4.16 Year of Diagnosis

In-Care Out-of-Care Total

Year Diagnosed with HIV # % # % # %

Before 1990 61 13.3% 21 8.8% 82 11.8%

1990-1995 70 15.3% 20 8.3% 90 12.9%

1996-1999 56 12.3% 23 9.6% 79 11.3%

2000-2004 77 16.8% 38 15.8% 115 16.5%

2005-2007 39 8.5% 24 10.0% 63 9.0%

2008-2010 53 11.6% 29 12.1% 82 11.8%

2011-2013 43 9.4% 38 15.8% 81 11.6%

2014-2017 52 11.4% 46 19.2% 98 14.1%

No Response or Unclear Response 6 1.3% 1 0.4% 7 1.0%

Total 457 100.0% 240 100.0% 697 100.0%

In-Care n = 457; Out-of-Care n = 240; Combined In-Care n = 697

Differences exist in how quickly in-care and out-of-care consumers accessed HIV medical care.

 27% of in-care consumers report “seeing a doctor within one month of diagnosis” compared to 20% of out-of-care consumers.

 31% of in-care consumers report “seeing a doctor in less than three months of diagnosis.” This compares to 18% of out-of-care who sought care within three months.

 Less than 1% of in-care and only 9% of out-of-care consumers have not received HIV medical care.

 25% of in-care consumers waited more than six months to begin HIV medical care compared to 35% of out-of-care/returned to care consumers.

Table 4.17

After Diagnosis

In-Care Out-of-Care Total

How Soon After Your Diagnosis Did You Go To See a Doctor About Your HIV? # % # % # %

In less than 1 month 121 26.5% 47 19.6% 168 24.1%

In less than 3 months 143 31.3% 42 17.5% 185 26.5%

Within 3 to 6 months 73 16.0% 43 17.9% 116 16.6%

After more than 6 months 116 25.4% 85 35.4% 201 28.8%

I have not received HIV medical care 4 0.9% 22 9.2% 26 3.7%

No Response 0 0.0% 1 0.4% 1 0.1%

Total 457 100.0% 240 100.0% 697 100.0%

In-Care n = 457; Out-of-Care n = 240; Combined In-Care n = 697

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ACCESS TO HIV CARE FOR THE INCARCERATED Approximately 13% of the total sample were incarcerated for one month or more in the last two years. This was true for both in-care and out-of-care consumers.

Table 4.18 Incarceration

In-Care Out-of-Care Total

Have you been in Jail or Prison for more than 1 month in the last 2 years? # % # % # %

Yes 57 12.5% 30 12.5% 87 12.5%

No 400 87.5% 210 87.5% 610 87.5%

Total 457 100.0% 240 100.0% 697 100.0%

In-Care n = 457; Out-of-Care n = 240; Combined In-Care n = 697

Eighty percent of HIV positive respondents reported receiving care while incarcerated.

 A larger proportion of in-care (84%) consumers received care than out-of-care (73%) consumers.

Table 4.19 HIV Care While Incarcerated

In-Care Out-of-Care Total

Did you receive HIV Medical Care While in Jail or Prison? # % # % # %

Yes 48 84.2% 22 73.3% 70 80.5%

No 9 15.8% 8 26.7% 17 19.5%

Total 57 100.0% 30 100.0% 87 100.0%

In-Care n = 57; Out-of-Care n = 30; Combined In-Care n = 87

Previously incarcerated respondents provided a number of issues that stopped them from getting HIV care. These include:

 “Afraid to tell others I’m HIV positive” was the number one reason among in-care consumers (25%).

 Among out-of-care consumers, “Couldn’t find a place to live,” and “Couldn’t stop using drugs or alcohol,” tied for the primary reason (23%).

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Table 4.20 HIV Care After Incarceration

In-Care Out-of-Care Total

After you were released, did any of the following stop you from getting HIV care? (Check all that apply) # % # % # %

Afraid to tell others I am HIV positive 14 24.6% 4 13.3% 18 20.7%

Could not find a place to live 5 8.8% 7 23.3% 12 13.8%

Did not know where to go for medical care 7 12.3% 4 13.3% 11 12.6%

Did not know where to go for an intake or to get case management 3 5.3% 6 20.0% 9 10.3%

Could not stop using drugs and/or alcohol 2 3.5% 7 23.3% 9 10.3%

Fear of discrimination, harassment, denial of service, or violence 1 1.8% 4 13.3% 5 5.7%

None of the above 34 59.6% 9 30.0% 43 49.4%

In-Care n = 57; Out-of-Care n = 30; Combined In-Care n = 87. Respondents were permitted to choose more than one.

BARRIERS TO CARE In-care consumers were asked why it was hard for them to get HIV care in the last year. Multiple responses were allowed. Nearly 57% of the in-care respondents indicated that it was not hard to get medical care. Problems that were cited include:

 Amount of time it takes at the clinic (15%).

 Paperwork required (13%).

 Lack of transportation, making it difficult to get to care (12%).

 The time it takes to get an appointment (9%).

 I cannot afford the co-pays, deductibles and other treatment costs (9%).

Table 4.21 HIV Medical Care Potential Problems

In-Care

In-Care

In the past year, why was it hard for you to get HIV medical care? (Check all that apply) # %

It was not hard to get medical care 258 56.5%

Amount of time it takes at the clinic 69 15.1%

Paperwork needed 59 12.9%

I do not have transportation so it's hard to get there 55 12.0%

The time it takes to get an appointment 43 9.4%

I cannot afford the co-pays, deductibles, and other costs of treatments and medicines 41 9.0%

No weekend hours 40 8.8%

I have to miss work to go to medical appointments 34 7.4%

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In-Care

In the past year, why was it hard for you to get HIV medical care? (Check all that apply) # %

No evening hours (after 5 pm) 33 7.2%

Sometimes I do not feel well enough to go to my appointment 26 5.7%

Other 22 4.8%

I am afraid of being seen at the clinic 17 3.7%

The clinic only treats HIV and no other medical conditions 12 2.6%

I do not feel mentally able to deal with the treatment 8 1.8%

The staff does not understand my culture 5 1.1%

I am in a domestic violence/sexual assault situation 2 0.4%

It is too hard to follow the medical advice 1 0.2%

The staff does not speak my language 1 0.2%

In-Care n = 457; Out-of-Care n = 240; Combined In-Care n = 697. Respondents were permitted to choose more than one.

Thirty-five percent of out-of-care consumers also indicated it was not difficult to obtain care. However, for those who did find it difficult the biggest barriers were: The paperwork needed (21%), the amount of time it takes at the clinic (20%). “I do not have transportation to get there” and “I cannot afford the deductible and other costs of treatment”, tied for third with each receiving 16% of responses.

Table 4.22 HIV Medical Care Potential Problems

Out-of-Care

Out-of-Care

In the past year, why was it hard for you to get HIV medical care? (Check all that apply) # %

It was not hard to get medical care 85 35.4%

Paperwork needed 50 20.8%

Amount of time it takes at the clinic 49 20.4%

I do not have transportation so it's hard to get there 38 15.8%

I cannot afford the co-pays, deductibles, and other costs of treatments and medicines 38 15.8%

The time it takes to get an appointment 35 14.6%

No evening hours (after 5 pm) 28 11.7%

No weekend hours 26 10.8%

I am afraid of being seen at the clinic 25 10.4%

I have to miss work to go to medical appointments 24 10.0%

Sometimes I do not feel well enough to go to my appointment 22 9.2%

I do not feel mentally able to deal with the treatment 19 7.9%

Other 19 7.9%

It is too hard to follow the medical advice 15 6.3%

The clinic only treats HIV and no other medical conditions 11 4.6%

The staff does not understand my culture 8 3.3%

I am in a domestic violence/sexual assault situation 3 1.3%

The staff does not speak my language 2 0.8%

Out-of-Care n = 240. Respondents were permitted to choose more than one.

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Reasons for Not Getting Care Fifty-seven consumers who were out-of-care for the last 12 months were asked to provide their reasons for not getting care. Respondents were given a list of reasons and an opportunity to provide additional reasons for being out-of-care. Responses included:

 Nearly 60% stated they didn’t feel sick.

 30% said, “I do not want to think about being HIV+”.

 28% did not want to take medications.

 23% cited a lack of money to pay for care.

 18% either didn’t want to be seen at a clinic, had a hard time getting to the clinic due to transportation, or found it was too much trouble.

Table 4.23

Not Getting HIV Medical Care Out-of-Care

Out-of-Care

Why are you not getting HIV medical care? (Check all that apply) # %

I do not feel sick 34 59.6%

I do not want to think about being HIV positive 17 29.8%

I do not want to take medicines 16 28.1%

I do not have money to pay 13 22.8%

It is too much trouble 10 17.5%

I am afraid to be seen at the clinic 10 17.5%

It is hard to get there (transportation) 10 17.5%

I use drugs or alcohol 9 15.8%

The clinic asks too many personal questions 7 12.3%

Other 7 12.3%

I do not need or want medical care 6 10.5%

I am afraid to get medical care 6 10.5%

Too much paperwork is needed 5 8.8%

Long waiting time to get an appointment 5 8.8%

The appointments cause problems with my job 2 3.5%

I do not have needed identification (ID)/my ID does not match who I am 2 3.5%

Services are not in my language 0 0.0%

I do not have legal status in the U.S. 0 0.0%

I do not like the physical exam 0 0.0%

Out-of-Care n = 57. (Answered No to Q4, Q5 AND Q6) Respondents were permitted to choose more than one.

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Reasons for Dropping Out of Care One hundred and sixty-seven consumers who had dropped out-of-care for at least six months in the last five years were asked why they dropped out of care.

 Substance abuse (alcohol or drugs) was the most frequent reason for dropping out of care identified by 42% of respondents.

 “It was hard to keep appointments” was indicated by 32% of respondents.

 “I did not feel sick” was cited by 27% of respondents.

 “I was tired of taking medications” was mentioned by 26% of the respondents.

 “I didn’t have money” was cited by nearly 25% of respondents.

 “I needed a break” was cited by 20% of respondents.

Table 24 Total Sample: Out-of-Care – Dropping Out of Care

Out-of-Care

In the past year, why was it hard for you to get HIV medical care? (Check all that apply) # %

It was hard to keep appointments 54 32.3%

I was using drugs 47 28.1%

I did not feel sick 45 26.9%

I was tired of taking medicines 44 26.3%

I did not have money 41 24.6%

I needed a break 33 19.8%

I was tired of going to the clinic 31 18.6%

Other 30 18.0%

It was hard to get to the clinic (transportation) 28 16.8%

I was using alcohol 23 13.8%

The appointments took too long 21 12.6%

I did not need or want medical care 19 11.4%

I moved and did not know where to go 19 11.4%

The staff does not understand my culture 9 5.4%

Staff does not understand my language 3 1.8%

Out-of-Care n = 167. Respondents were permitted to choose more than one.

SERVICE NEEDS The consumer survey asked participants to identify their top five service needs. The 10 most frequently identified needed services by all consumer survey respondents include:

 Dental visits.

 Food bank.

 HIV outpatient medical care.

 Help paying for prescriptions/medication.

 Medical care from a specialist referred by their HIV medical provider.

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 Primary medical care not related to HIV.

 Transportation to medical care, bus passes, van service.

 Emergency financial assistance for rent/mortgage or utilities.

 Emergency long term rental assistance voucher.

 Help paying for co-pays and deductibles. Although the top 10 remained quite similar to the 2013 survey, transportation and emergency financial assistance for rent/mortgage and utilities was ranked 7th and 8th, respectively, in 2016; and mental health counseling and medical case management dropped out of the top 10. In-care respondents identified one other service in their top 10:

 Medical case management. Out-of-care respondents identified one other service in their top 10 services:

 Mental health counseling.

Table 4.25 Service Needs

In-Care Out-of-Care Total

From the list below, check the 5 services you need the most: # % # % # %

Dental Visits 269 58.9% 134 55.8% 403 57.8%

Food Bank 232 50.8% 102 42.5% 334 47.9%

HIV Outpatient Medical Care 224 49.0% 103 42.9% 327 46.9%

Help paying for prescription medicines 146 31.9% 78 32.5% 224 32.1%

Medical Care from a Specialist referred by your HIV medical provider

124 27.1% 52 21.7% 176 25.3%

Primary Medical Care for general medical care not related to HIV

109 23.9% 66 27.5% 175 25.1%

Transportation to Medical Care—Bus Pass/Van Service

111 24.3% 60 25.0% 171 24.5%

Emergency Financial Assistance for Rent/Mortgage or Utilities

103 22.5% 44 18.3% 147 21.1%

Emergency Long-Term Rental Assistance (Voucher) 90 19.7% 53 22.1% 143 20.5%

Help paying for co-pays and deductibles for HIV medical care visits and medications

93 20.4% 45 18.8% 138 19.8%

Medical Case Management 91 19.9% 42 17.5% 133 19.1%

Mental Health Counseling 79 17.3% 53 22.1% 132 18.9%

Employment Services 57 12.5% 44 18.3% 101 14.5%

Non-Medical Case Management 56 12.3% 29 12.1% 85 12.2%

Nutritional Counseling 60 13.1% 25 10.4% 85 12.2%

Transportation to Other Services 55 12.0% 22 9.2% 77 11.0%

Education Services 30 6.6% 36 15.0% 66 9.5%

Legal Services to help you work through a problem obtaining services/benefits, outline advance directives or establish guardianships

43 9.4% 22 9.2% 65 9.3%

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In-Care Out-of-Care Total

From the list below, check the 5 services you need the most: # % # % # %

Job Training Services 28 6.1% 36 15.0% 64 9.2%

If you have health insurance, help with continuing this insurance

41 9.0% 14 5.8% 55 7.9%

Facility Based Housing (Assisted Living Facility) 32 7.0% 15 6.3% 47 6.7%

Outpatient Substance Abuse Treatment 11 2.4% 18 7.5% 29 4.2%

Child Care while at a medical or other 11 2.4% 6 2.5% 17 2.4%

Respite Care for Adults (Activities during day) 10 2.2% 5 2.1% 15 2.2%

Early Intervention to help you get into HIV medical care

6 1.3% 9 3.8% 15 2.2%

Translation or Interpretation 7 1.5% 3 1.3% 10 1.4%

Respite Care for HIV positive children 2 0.4% 1 0.4% 3 0.4%

In-Care n = 457; Out-of-Care n = 240; Combined In-Care n = 697

INTERVIEWS WITH KEY INFORMANTS The comments presented below represent the beliefs, opinions and experiences of the key informants interviewed. Key informants were asked what barriers were faced by consumers who never linked to care. Structural Barriers

 Housing

 Mental health services

 Language barriers

 Substance abuse and untreated mental health issues

 Structural factors keep people from coming into care such as high poverty rates, lack of access to general medical care

 One of the first barriers for consumers is that they’ve never been linked to (any) care Accessibility/Availability and Acceptability

 Accessible care and the perception that providers are against them, rather than having a common goal of good health

 Weekend and evening hours for those who are employed

 Awareness that services are available

 Making it a positive experience for clients will help to promote its use in those not linked

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Care Coordination

 Patient navigation – We have a very intense, close navigation piece that we do with our clients when linking them to care.

 Delays in linking them to care – once there – is a delay; we can lose the patient.

 It’s going to take more funds to fund caseworkers and/or case managers to follow these individuals through care.

 They may give them a name and phone number, “Here call this number.” But, I think the discussion needs to be more than a name and phone number – to be told, don’t worry about the cost, someone will help with that.

 I’ve heard there could be a long wait at ____________. Asked what barriers impact those who drop out-of-care, respondents indicated many of the same reasons, along with issues of stigma, acceptance and treatment fatigue.

 (Lack of) acceptance of the diagnosis does prevent staying in or being linked long term.

 Some don’t want to go to the doctor in their community, so they go to __________ . . . I still think it goes back to stigma and who is going to see them walking into that clinic and perhaps maybe someone saw them and they never went back.

 People have needs that trump their medical care; needs such as insufficient housing, food and transportation issues.

 Other barriers would be hours . . . The hours that these agencies provide service, especially if the person is working.

 Transportation is also one of the issues and having services on Saturday, Sunday and evenings would be helpful.

 Lack of housing.

 Treatment fatigue – folks are tired of following up with all of the appointments or tired of taking their medications.

 Fatigue around the amount of paperwork and the things that have to be done to stay in care – particularly if you are uninsured and have to access Ryan White-funded services.

 There’s so much associated with making sure all the paperwork and stuff is filled out for you to get your medications or even care.

 Lack of knowledge of the importance of staying in care.

 Substance abuse is one of the barriers to remaining in care. But, also accepting patients who do have a substance abuse issue and understanding it’s something that may continue.

FOCUS GROUP INTERVIEWS The responses presented below represent the beliefs, opinions and experiences of the participants, who were asked what barriers exist for consumers who know their status and are not in care. Consumer Focus Group

 They have no clue as to what is out there. There is no current list on what the services are.

 Some barriers are transportation, housing, mental health, substance abuse, homelessness are the main ones.

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 Stability is the key, if we can stabilize a person’s housing, -- when you have somewhere to eat, somewhere to keep your medicine in the refrigerator, you are more apt to comply with medications and appointments.

 Transportation has been limited, the housing crisis is out of whack; and we need to think about the recently incarcerated.

Provider Focus Group

 Denial is the most common cause I hear and they aren’t ready to deal with it.

 I think it’s just difficult to navigate wait times for case management.

 Stigma is always a big issue.

 Mental illness.

 Distrust of medical providers.

 Homeless people are a huge issue and they are so at risk. For homeless people the last thing in their minds is HIV.

 Stable housing.

 Access to crisis counseling or support.

 Geography; pretty much all of our services are in central Dallas.

 Not having the appropriate information.

 Having to wait 6-8-12 weeks to get an appointment.

 Women sometimes don’t come back for care because they are busy taking care of others and put that before themselves and their health.

 There are so many clients that say – “Please don’t tell __________.” Planning Council Focus Group

 The main barrier is that they don’t quite understand why it’s important to stay in care.

 Meeting eligibility requirements, transportation, access to care; those are the three biggest.

 Transportation, co-morbidities of mental health and substance abuse, and culture and stigma.

 If you have someone who needs food or housing the last thing on their mind is going to be the doctor.

 A lot of our clients have mental issues or depression issues, they don’t remember appointments. RECOMMENDATIONS Newly Diagnosed 1. Enhance early intervention services (EIS) to facilitate effective linkage of newly diagnosed patients

to medical care. Consider a structured regional patient navigation program and multi-disciplinary collaborative that engages Outreach, EIS and ambulatory/outpatient medical care.

 Establish a definition of effective linkage.

 Monitor EIS performance with regard to linkage to care practices. 2. Work with EIS to identify structural, agency and client-based barriers to care.

 Convene a task force to identify issues and develop recommendations to reduce barriers to care. Communicate recommendations to the multi-disciplinary collaborative and/or patient navigation program.

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 Develop criteria to identify patients who are at high risk for dropping out of care, and expand retention strategies targeted to them. Follow-up after initiation of treatment for up to one year to assure retention in care.

 Invite non-Ryan White providers to participate in the collaborative effort to build communications and to develop referral linkages for patients (especially in light of funding uncertainties).

Lost to Care 3. Encourage providers via funding mechanism/criteria to strengthen programs aimed at maintaining at-

risk populations in care.

 Work with DSHS to maintain the out-of-care list, and utilize that list to target PLWH lost to care.

 Expand lost-to-care programs at all Ryan White and HOPWA sites.

 Develop a provider collaborative to enable networking and sharing of best practices for maintaining retention in care and rapid identification of those who would be lost to care.

Overarching Issues 4. Housing along with transportation are major risk factors for not entering or dropping out-of-care.

Therefore, evaluate options to expand these services or, alternatively, increase effectiveness of existing resources.

5. Review HOPWA contracts and beneficiaries to locate potential out-of-care consumers and address

barriers to receiving housing and other support services.

6. Clients should receive education and information about the importance of remaining in care at every contact with the system (EIS, medical visit, case management contact, etc.). Even though consumers are required to be in HIV medical care to receive RWHAP support services, this message needs to be repeated at every juncture.

7. Consider matching peer support personnel/patient navigators to high-risk PLWH to support them in

linkage and retention in care.

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BLACK/AFRICAN-AMERICAN MEN AND WOMEN The consumer survey sample was completed by 387 Black/African-Americans2 living with HIV/AIDS, comprising 56% of the total sample. The Black/African-American men included 253 (55%) in-care and 134 (56%) out-of-care consumers.

 Black/African-Americans in the Dallas EMA had the highest infection rate in the region; 1,036.3/100,000 in 2015.

 In 2015, the rate of new infections exceeded more than three times that of Whites/Caucasians and more than three times that of Hispanics.

 Black/African-American MSM had the highest unmet need (24%) when compared with White/Caucasian and Hispanic MSM (17% and 23%, respectively). Findings were similar for MSM/IDU, with 23% of Black/African-Americans having unmet need and 22% of Hispanic MSM with unmet need compared to 16% of White/Caucasians.

 Unmet need among those with heterosexual contact transmission found Black/African-American men with second highest unmet need (29%). Unmet need among Hispanics with heterosexual contact transmission had the highest unmet need (32%).

RESPONDENT OVERVIEW Demographics Gender identity among Black/African-American resembles the overall sample closely.

 Black/African-American men represented 71% of the African-American survey respondents, while the total survey was 75% male.

 Women represented 27% of the Black/African-American survey sample, while women represented 23% of the overall sample.

 A slightly higher percentage of in-care (28%) respondents were women than out-of-care (25%).

Table 4.26 Gender

Black/African-American Men & Women

In-Care Out-of-Care Total Total Sample

Gender Identity # % # % # % %

Male 179 70.8% 97 72.4% 276 71.3% 75.0%

Female 71 28.1% 34 25.4% 105 27.1% 22.8%

Transgender / Other Gender Identity 3 1.2% 3 2.2% 6 1.6% 2.2%

Total 253 100.0% 134 100.0% 387 100.0% 100.0%

In-Care n = 253; Out-of-Care n = 134; Combined In-Care/Out-of-Care n = 387

2 The consumer survey included a racial option of “Black or Black/African-American,” so this discussion includes consumers who self-designate as either “Black or Black/African-American.”

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The age ranges of Black/African-American respondents were similar but slightly younger than those for the overall survey sample.

 4% of Black/African-American respondents were youths ages 13–24 compared to 3% in the total sample.

 18% of Black/African American respondents were 25-34 years old compared to 16% in the total sample.

 20% of Black/African-American respondents and 20% of the total respondent sample were between 34-44 years old.

Table 4.27

Age Black/African-American Men & Women

In-Care Out-of-Care

Total Black/African-

American Total

Sample

Age Cohort # % # % # % %

Age 13-24 3 1.2% 11 8.2% 14 3.6% 3.2%

Age 25-34 35 13.8% 35 26.1% 70 18.1% 16.2%

Age 35-44 55 21.7% 22 16.4% 77 19.9% 19.9%

Age 45-54 69 27.3% 41 30.6% 110 28.4% 30.4%

Age 55+ 87 34.4% 21 15.7% 108 27.9% 28.1%

Age Not Reported 4 1.6% 4 3.0% 8 2.1% 2.2%

Total 253 100.0% 134 100.0% 387 100.0% 100.0%

In-Care n = 253; Out-of-Care n = 134; n = 387

County of Residence Black/African-American survey respondents were almost all from Dallas County, but Denton and Collin Counties were also represented.

Table 4.28 County of Residence

Black/African-American Men & Women

In-Care Out-of-Care Total

Black/AA Total

Sample

County # % # % # % %

Collin 8 3.2% 3 2.2% 11 2.8% 3.4%

Cooke 0 0.0% 0 0.0% 0 0.0% 0.4%

Dallas 221 87.4% 121 90.3% 342 88.4% 83.1%

Denton 22 8.7% 9 6.7% 31 8.0% 9.5%

Ellis 0 0.0% 0 0.0% 0 0.0% 0.1%

Fannin 0 0.0% 0 0.0% 0 0.0% 0.1%

Grayson 2 0.8% 1 0.7% 3 0.8% 3.2%

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In-Care Out-of-Care Total

Black/AA Total

Sample

County # % # % # % %

Henderson 0 0.0% 0 0.0% 0 0.0% 0.0%

Hunt 0 0.0% 0 0.0% 0 0.0% 0.1%

Kaufman 0 0.0% 0 0.0% 0 0.0% 0.0%

Navarro 0 0.0% 0 0.0% 0 0.0% 0.0%

Rockwall 0 0.0% 0 0.0% 0 0.0% 0.0%

Total 253 100.0% 134 100.0% 387 100.0% 3.4%

In-Care n = 253; Out-of-Care n = 134; Combined In-Care n = 387

Transmission Mode Considering transmission mode as identified on the consumer survey, 43% of Black/African-Americans reported MSM, 41% heterosexual contact, and 5% reported IDU. Compared to the total sample, a greater percentage of Black/African-American respondents identified with heterosexual contact (41% vs. 32%).

 Comparing transmission mode of in-care and out-of-care Black/African-Americans:  In-care Black/African-American respondents represented a larger percentage reporting

heterosexual contact transmission, 45% vs. 34% of those out-of-care.  In-care Black/African-American respondents have a smaller percentage of reporting MSM

transmission, 39% vs. 51% of those out of care. In-care Black/African-American respondents have a higher percentage reporting sharing needles/IDU, 6% for in-care vs. 5% for out-of-care.

Table 4.29

Transmission Mode Black/African-American Men & Women

In-Care Out-of-Care Total

Black/AA Total

Sample

Transmission Mode # % # % # % %

MSM 99 39.1% 68 50.7% 167 43.2% 50.1%

IDU 15 5.9% 6 4.5% 21 5.4% 6.0%

MSM + IDU 1 0.4% 2 1.5% 3 0.8% 2.4%

Heterosexual Contact 113 44.7% 45 33.6% 158 40.8% 31.9%

Do Not Know 16 6.3% 11 8.2% 27 7.0% 7.9%

Other 23 9.1% 9 6.7% 32 8.3% 9.6%

In-Care n = 253; Out-of-Care n = 134; Combined In-Care n = 387

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Educational Attainment and Employment Educational attainment of in-care and out-of-care Black/African-Americans was similar to the total survey sample.

Table 4.30 Educational Attainment

Black/African-American Men & Women

In-Care Out-of-Care Total

Black/AA Total

Sample

Educational Attainment # % # % # % %

Eighth Grade or Less 12 4.7% 1 0.7% 13 3.4% 3.3%

Some High School 28 11.1% 22 16.4% 50 12.9% 12.9%

High School Graduate/GED 107 42.3% 52 38.8% 159 41.1% 34.9%

Technical or Trade School 9 3.6% 8 6.0% 17 4.4% 4.9%

Some College 65 25.7% 38 28.4% 103 26.6% 28.8%

Completed College 20 7.9% 9 6.7% 29 7.5% 10.3%

Graduate Education 12 4.7% 3 2.2% 15 3.9% 4.0%

Other 0 0.0% 1 0.7% 1 0.3% 0.9%

Total 253 100.0% 134 100.0% 387 100.0% 100.0%

In-Care n = 253; Out-of-Care n = 134; Combined In-Care n = 387

Only 6% of Black/African-American PLWHs served in the military. This was similar to the total sample. This included nearly 9% of those in-care and <2% of those out-of-care.

Table 4.31 Military Service

Black/African-American Men & Women

In-Care Out-of-Care Total Black/AA

Total Sample

Served in Military # % # % # % %

Yes 22 8.7% 2 1.5% 24 6.2% 5.9%

No 230 90.9% 132 98.5% 362 93.5% 93.5%

Do Not Want To Say 1 0.4% 0 0.0% 1 0.3% 0.6%

Total 253 100.0% 134 100.0% 387 100.0% 100.0%

In-Care n = 253; Out-of-Care n = 134; Combined In-Care n = 387

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Likewise, Black/African-Americans employment status was similar to the total sample.

 79% of Black/African-Americans were unemployed compared to 76% of the total sample.

Table 4.32 Employment Status

Black/African-American Men & Women

In-Care Out-of-Care Total

Black/AA Total

Sample

Employment Status # % # % # % %

Work Full-Time 33 13.0% 11 8.2% 44 11.4% 13.3%

Work Part-Time 20 7.9% 17 12.7% 37 9.6% 11.0%

Not Working 200 79.1% 106 79.1% 306 79.1% 75.6%

Total 253 100.0% 134 100.0% 387 100.0% 100.0%

In-Care n = 253; Out-of-Care n = 134; Combined In-Care n = 387

Of the 306 Black/African-Americans who were not working:

 46% were on disability (similar to the 45% of the total sample).

 16% indicated their health precluded them from working even though they were not on disability.

 22% were looking for jobs, 33% of whom were out-of-care compared to 16% of those in-care.

Table 4.33 Unemployed Status

Black/African-American Men & Women

In-Care Out-of-Care Total

If You Are Not Working, Which Best Describes You? # % # % # %

I am a student 9 4.5% 5 4.7% 14 4.6%

I am looking for a job 32 16.0% 35 33.0% 67 21.9%

I am retired 11 5.5% 2 1.9% 13 4.2%

I work as a volunteer 5 2.5% 1 0.9% 6 2.0%

My health keeps me from working - I am not on disability 34 17.0% 16 15.1% 50 16.3%

My health keeps me from working - I am on disability 102 51.0% 40 37.7% 142 46.4%

Other 7 3.5% 7 6.6% 14 4.6%

Total 200 100.0% 106 100.0% 306 100.0%

In-Care n = 200; Out-of-Care n = 106; Combined In-Care n = 306

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Income Incomes for Black/African-Americans were slightly lower than the total sample. Seventy-four percent of Black/African-Americans earned less than $950 a month compared to 68% of the total sample.

Table 4.34 Income

Black/African-American Men & Women

In-Care Out-of-Care Total

Black/AA Total

Sample

Monthly Income # % # % # % %

Less than $950 177 70.0% 110 82.1% 287 74.2% 68.1%

$950 - $1,900 50 19.8% 20 14.9% 70 18.1% 22.5%

$1,901 - $2,800 20 7.9% 2 1.5% 22 5.7% 6.7%

More than $2,800 6 2.4% 2 1.5% 8 2.1% 2.6%

Total 253 100.0% 134 100.0% 387 100.0% 100.0%

In-Care n = 253; Out-of-Care n = 134; Combined In-Care n = 387

Housing Situation Half of Black/African-American men and women report living “in an apartment/house/mobile home that I own or rent in my own name.”

 13% have permanent residency, relative to 14% in total sample.  7% in a parent or relative’s home.  6% in another person’s apartment or home.

 12% have a temporary residency situation, while 10% of the total sample have a temporary situation.

 6% in a parent or relative’s home.  6% in another person’s apartment or home.

 9% report homelessness, compared to 8% in the total survey.  4% on the street or in a car.  5% report living in a homeless shelter.

 9% report living in an assisted living facility, higher than 7% in the total sample.

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Table 4.35 Housing Situation

Black/African-American Men & Women

In-Care Out-of-Care Total Total Sample

Where do you live now? (check only one) # % # % # % %

In an apartment/house/mobile home that I own or rent in my name

141 55.7% 53 39.6% 194 50.1% 52.2%

At my parent's or a relative's home- permanent

18 7.1% 7 5.2% 25 6.5% 8.3%

In a "supportive living" facility (Assisted Living Facility)

19 7.5% 16 11.9% 35 9.0% 7.3%

At another person's apartment/home- permanent

9 3.6% 14 10.4% 23 5.9% 5.9%

At another person's apartment/home- temporary

12 4.7% 12 9.0% 24 6.2% 5.6%

At my parent's or a relative's home-temporary 14 5.5% 8 6.0% 22 5.7% 4.6%

Homeless (on the street or in car) 10 4.0% 5 3.7% 15 3.9% 4.0%

In a half-way house, transitional housing or treatment facility (drug or psychiatric)

8 3.2% 4 3.0% 12 3.1% 4.0%

Homeless Shelter 9 3.6% 11 8.2% 20 5.2% 3.6%

In a rooming or boarding house 5 2.0% 2 1.5% 7 1.8% 2.0%

Residential hospice facility or skilled nursing home

0 0.0% 0 0.0% 0 0.0% 0.1%

Domestic Violence Shelter 0 0.0% 0 0.0% 0 0.0% 0.0%

Other 8 3.2% 2 1.5% 10 2.6% 2.3%

Total 253 100.0% 134 100.0% 387 100.0% 100.0%

In-Care n = 253; Out-of-Care n = 134; Combined In-Care/Out-of-Care n = 387

Substance Use and Mental Health Disorders Consumers were asked about drug use in the last six months responded as follows:

 55% of Black/African-American PLWH responded “Yes” to the use of alcohol or drugs.

 A higher percent (69%) of those using drugs or alcohol were out-of-care compared to in-care (48%).

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Table 4.36 Substance Use in the Last 6 Months

Black/African-American Men & Women

In-Care Out-of-Care Total

Black/AA Total

Sample

Substance Use # % # % # % %

Have Used Drugs or Alcohol in Past 6 Months 122 48.2% 92 68.7% 214 55.3% 56.2%

No Drugs Listed Used 131 51.8% 42 31.3% 173 44.7% 43.8%

Total 253 100.0% 134 100.0% 387 100.0% 100.0%

In-Care n = 253; Out-of-Care n = 134; Combined In-Care n = 387

The consumer survey asked about IV drug use with the following results:

 Only 3% of Black/African-American respondents admitted to injecting drugs, with 1% being in- care and nearly 5% being out-of-care.

 Over 60% refused to respond to the question.

Table 4.37 IV Drug Use in the Last Six Months

Black/African-American Men & Women

Have you injected substances in the past two months? In-Care Out-of-Care

Total Black/AA

Total Sample

IV Drug Use # % # % # %

Yes 4 1.6% 6 4.5% 10 2.6% 3.3%

No 88 34.8% 49 36.6% 137 35.4% 36.3%

No Response 161 63.6% 79 59.0% 240 62.0% 60.4%

Total 253 100.0% 134 100.0% 387 100.0% 100.0%

In-Care n = 253; Out-of-Care n = 134; Combined In-Care n = 387

The most frequent substance used in the last six months was alcohol (72%) followed by marijuana (52%) and stimulants (13%).

 A higher percentage of out-of-care respondents used stimulants (15%) compared to 11% of in- care respondents.

 7% of out-of-care respondents compared to

 10% of in-care respondents used opioids and morphine.

 3% of out-of-care respondents compared to 11% of in-care respondents used depressants.

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Table 4.38

Substances Used in the Last 6 Months Black/African-American Men & Women

In-Care Out-of-Care Total

Black/AA Total

Sample

Substance Use # % # % # % %

Alcohol 85 69.7% 70 76.1% 155 72.4% 69.1%

Marijuana 57 46.7% 54 58.7% 111 51.9% 46.4%

Depressants 13 10.7% 3 3.3% 16 7.5% 10.2%

Ketamine/PCP 0 0.0% 0 0.0% 0 0.0% 0.3%

Hallucinogens 1 0.8% 0 0.0% 1 0.5% 1.0%

Opioids and Morphine 12 9.8% 6 6.5% 18 8.4% 11.2%

Stimulants 14 11.5% 14 15.2% 28 13.1% 19.9%

Steroids not prescribed by your doctor 1 0.8% 0 0.0% 1 0.5% 0.8%

Prescription painkillers not prescribed by your doctor 8 6.6% 2 2.2% 10 4.7% 6.1%

Inhalants 2 1.6% 1 1.1% 3 1.4% 2.6%

In-Care n = 122; Out-of-Care n = 92; Combined In-Care n = 214

Black/African-American respondents who indicated they used alcohol were asked if they used alcohol more than three times a week.

 Similar to the total sample, 29% responded positively.

Table 4.39 Alcohol Use

Black/African-American Men & Women

In-Care Out-of-Care Total

Black/AA Total

Sample

Do you Drink Alcohol More Than 3 Times A Week?

# % # % # % %

Yes 18 21.2% 27 38.6% 45 29.0% 29.2%

No 67 78.8% 43 61.4% 110 71.0% 70.8%

Total 85 100.0% 70 100.0% 155 100.0% 100.0%

In-Care n = 85; Out-of-Care n = 70; Combined In-Care n = 155

Active Black/African-American substance abuse users were asked if they had thought about going to substance abuse treatment.

 28% responded positively.

 More out-of-care respondents (34%) had thought about getting into care than in-care respondents.

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Table 4.40 Considering Treatment

Black/African-American Men & Women

In-Care Out-of-Care Total

Black/AA Total

Sample

Have Thought About Seeking Substance Abuse Treatment

# % # % # % %

Yes 29 23.8% 31 33.7% 60 28.3% 28.4%

No 93 76.2% 59 64.1% 152 71.7% 71.6%

No Response 0 0.0% 2 2.2% 2 0.9% 1.3%

Total 122 100.0% 92 100.0% 212 100.0% 100.0%

In-Care n = 122; Out-of-Care n = 92; Combined In-Care n = 212

Free care (22%) and “admission to a program as soon as I am ready” (20%) were the most important considerations for getting into care. (Table not shown) Almost 25% of Black/African-American consumer survey respondents were diagnosed with depression.

 A slightly higher proportion of in-care consumers reported depression (26%) than those out-of- care (22%).

Table 4.41

Depression Diagnosis Black/African-American Men & Women

In-Care Out-of-Care Total

Black/AA Total

Sample

Have You Received Medical Treatment for Depression in the Last 12 Months?

# % # % # % %

Yes 66 26.1% 30 22.4% 96 24.8% 29.7%

No 187 73.9% 104 77.6% 291 75.2% 70.3%

Total 253 100.0% 134 100.0% 387 100.0% 100.0%

In-Care n = 253; Out-of-Care n = 134; Combined In-Care n = 387

DIAGNOSIS AND REFERRAL FOR CARE Slight differences existed between diagnoses dates of Black/African-American in-care and out-of-care consumers with out-of-care consumers being more recently diagnosed.

 More than 46% of consumers were diagnosed since 2005; this includes 55% of out-of-care consumers and 42% of in-care consumers.

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Table 4.42

Year of Diagnosis Black/African-American Men & Women

In-Care Out-of-Care Total

Black/AA Total

Sample

Year Diagnosed with HIV # % # % # % %

Before 1990 32 12.6% 13 9.7% 45 11.6% 11.8%

1990-1995 39 15.4% 12 9.0% 51 13.2% 12.9%

1996-1999 33 13.0% 15 11.2% 48 12.4% 11.3%

2000-2004 44 17.4% 20 14.9% 64 16.5% 16.5%

2005-2007 20 7.9% 10 7.5% 30 7.8% 9.0%

2008-2010 36 14.2% 16 11.9% 52 13.4% 11.8%

2011-2013 23 9.1% 18 13.4% 41 10.6% 11.6%

2014-2017 22 8.7% 30 22.4% 52 13.4% 14.1%

No Response or Unclear Response 4 1.6% 0 0.0% 4 1.0% 1.0%

Total 253 100.0% 134 100.0% 387 100.0% 100.0%

In-Care n = 253; Out-of-Care n = 134; Combined In-Care/Out-of-Care n = 387

Differences existed with respect to how quickly in-care and out-of-care Black/African-American consumers accessed medical care.

 28% of in-care compared to 15% of out-of-care consumers reported seeing a doctor within one month.

 28% of in-care Black/African-Americans compared to 19% of out-of-care Black/African-Americans reported seeing a doctor within three months.

 17% of in-care compared to 15% of out-of-care Black/African-Americans reported seeing the doctor within 3-6 months of diagnosis.

 26% of in-care compared to 27% of out-of-care consumers waited more than six months to see a doctor.

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Table 4.43 Care After Diagnosis

Black/African-American Men & Women

In-Care Out-of-Care Total

Black/AA Total

Sample

How Soon After Your Diagnosis Did You Go To See a Doctor About Your HIV?

# % # % # % %

In less than 1 month 71 28.1% 20 14.9% 91 23.5% 24.1%

In less than 3 months 71 28.1% 25 18.7% 96 24.8% 26.5%

Within 3 to 6 months 42 16.6% 20 14.9% 62 16.0% 16.6%

After more than 6 months 65 25.7% 49 36.6% 114 29.5% 28.8%

I have not received HIV medical care 4 1.6% 19 14.2% 23 5.9% 3.7%

No Response 0 0.0% 1 0.7% 1 0.3% 0.1%

Total 253 100.0% 134 100.0% 387 100.0% 100.0%

In-Care n = 253; Out-of-Care n = 134; Combined In-Care n = 387

ACCESS TO HIV CARE FOR THE INCARCERATED Approximately 12% of Black/African-American survey respondents were incarcerated for one month or more in the last 12 months.

Table 4.44 Incarceration

Black/African-American Men & Women

In-Care Out-of-Care Total

Black/AA Total

Sample

Have you been in Jail or Prison for more than 1 month in the last 2 years?

# % # % # % %

Yes 29 11.5% 18 13.4% 47 12.1% 12.5%

No 224 88.5% 116 86.6% 340 87.9% 87.5%

Total 253 100.0% 134 100.0% 387 100.0% 100.0%

In-Care n = 253; Out-of-Care n = 134; Combined In-Care n = 387

Eighty-six percent of in-care Black/African-American consumers received care while in prison compared to 61% of out-of-care respondents. In total, fewer Black/African-American respondents received HIV care while incarcerated (77% vs 81%).

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Table 4.45 HIV Care While Incarcerated

Black/African-American Men & Women

In-Care Out-of-Care Total

Black/AA Total

Sample

Did you receive HIV Medical Care While in Jail or Prison?

# % # % # % %

Yes 25 86.2% 11 61.1% 36 76.6% 80.5%

No 4 13.8% 7 38.9% 11 23.4% 19.5%

Total 29 100.0% 18 100.0% 47 100.0% 100.0%

In-Care n = 29; Out-of-Care n = 18; Combined In-Care n = 47

Previously incarcerated Black/African-Americans provided several reasons for not seeking care after their release. These included:

 “Afraid to tell others, I am HIV+.” (23%)

 “Did not know where to go for medical care.” (17%)

 “Did not know where to go for intake or case management.” (15%)

Table 4.46 HIV Care After Incarceration

Black/African-American Men & Women

In-Care Out-of-Care Total

Black/AA Total

Sample

After you were released, did any of the following stop you from getting HIV care? (Check all that apply)

# % # % # % %

Afraid to tell others I am HIV positive 9 31.0% 2 11.1% 11 23.4% 20.7%

Could not find a place to live 2 6.9% 4 22.2% 6 12.8% 13.8%

Did not know where to go for medical care 5 17.2% 3 16.7% 8 17.0% 12.6%

Did not know where to go for an intake or to get case management 3 10.3% 4 22.2% 7 14.9% 10.3%

Could not stop using drugs and/or alcohol 1 3.4% 3 16.7% 4 8.5% 10.3%

Fear of discrimination, harassment, denial of service, or violence 0 0.0% 3 16.7% 3 6.4% 5.7%

None of the above 13 44.8% 6 33.3% 19 40.4% 49.4%

In-Care n = 29; Out-of-Care n = 18; Combined In-Care n = 47. Respondents were permitted to choose more than one.

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BARRIERS TO CARE In-Care Fifty-one percent of in-care Black/African-Americans did not find it hard to get care compared to 57% of the total sample of consumers. The amount of time it takes at the clinic, paperwork and transportation were the predominant barriers noted. The rank order of responses was similar to those provided by the total in-care sample

Table 4.47 HIV Medical Care Potential Problems

Black/African-American Men & Women In-Care

In-Care

Black/AA Total

Sample

In the past year, why was it hard for you to get HIV medical care? (Check all that apply) # % %

It was not hard to get medical care 130 51.4% 56.5%

Amount of time it takes at the clinic 43 17.0% 15.1%

Paperwork needed 35 13.8% 12.9%

I do not have transportation so it's hard to get there 32 12.6% 12.0%

I cannot afford the co-pays, deductibles, and other costs of treatments and medicines 26 10.3% 9.4%

The time it takes to get an appointment 27 10.7% 9.0%

No weekend hours 17 6.7% 8.8%

No evening hours (after 5 pm) 16 6.3% 7.4%

I have to miss work to go to medical appointments 17 6.7% 7.2%

Sometimes I do not feel well enough to go to my appointment 15 5.9% 5.7%

I am afraid of being seen at the clinic 16 6.3% 4.8%

I do not feel mentally able to deal with the treatment 4 1.6% 3.7%

The clinic only treats HIV and no other medical conditions 5 2.0% 2.6%

It is too hard to follow the medical advice 1 0.4% 1.8%

The staff does not understand my culture 2 0.8% 1.1%

I am in a domestic violence/sexual assault situation 0 0.0% 0.4%

The staff does not speak my language 0 0.0% 0.2%

Other 10 4.0% 0.2%

In-Care n = 253; Out-of-Care n = 134; Combined In-Care n = 387 Respondents were permitted to choose more than one.

Twenty-seven percent of out-of-care Black/African-Americans indicated it was not hard to get care. However, for those who did find it hard, the following barriers were noted:

 22% cited the paperwork needed.

 20% cited the amount of time it takes at the clinic.

 17% cited the time it takes to get an appointment.

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Table 4.48 HIV Medical Care Potential Problems

Black/African-American Men & Women Out-of-Care

Out-of-Care

Black/AA

Total Out-of-

Care Sample

In the past year, why was it hard for you to get HIV medical care? (Check all that apply) # %

%

It was not hard to get medical care 36 26.9% 35.4%

Amount of time it takes at the clinic 27 20.1% 20.4%

Paperwork needed 29 21.6% 20.8%

I do not have transportation so it's hard to get there 21 15.7% 15.8%

I cannot afford the co-pays, deductibles, and other costs of treatments and medicines 22 16.4% 15.8%

The time it takes to get an appointment 23 17.2% 14.6%

No weekend hours 15 11.2% 10.8%

No evening hours (after 5 pm) 16 11.9% 11.7%

I have to miss work to go to medical appointments 18 13.4% 10.0%

Sometimes I do not feel well enough to go to my appointment 12 9.0% 9.2%

I am afraid of being seen at the clinic 16 11.9% 10.4%

I do not feel mentally able to deal with the treatment 10 7.5% 7.9%

The clinic only treats HIV and no other medical conditions 9 6.7% 4.6%

It is too hard to follow the medical advice 9 6.7% 6.3%

The staff does not understand my culture 7 5.2% 3.3%

I am in a domestic violence/sexual assault situation 0 0.0% 1.3%

The staff does not speak my language 0 0.0% 0.8%

Other 13 9.7% 7.9%

In-Care n = 253; Out-of-Care n = 134; Combined In-Care n = 387 Respondents were permitted to choose more than one.

Reason for Not Getting Care Fifty-seven Black/African-Americans who were out-of-care during the last 12 months were asked to provide reasons for not being in care. The most common reasons for not being in care were;

 “I did not feel sick” (53%)

 “I do not want to think about being HIV+” (25%)

 “I do not want to take medicines”, which tied for second (25%).

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Table 4.49 Why Are You Not Getting HIV Medical Care?

Black/African-American Men & Women Out-of-Care

Out-of-Care Black/AA

Total Out-of-Care

Sample

Why are you not getting HIV medical care? (Check all that apply) # %

I do not feel sick 30 52.6% 59.6%

I do not need or want medical care 4 7.0% 10.5%

I do not want to think about being HIV positive 14 24.6% 29.8%

I am afraid to get medical care 5 8.8% 10.5%

It is too much trouble 10 17.5% 17.5%

I do not want to take medicines 14 24.6% 28.1%

Too much paperwork is needed 4 7.0% 8.8%

I am afraid to be seen at the clinic 10 17.5% 17.5%

The appointments cause problems with my job 2 3.5% 3.5%

The clinic asks too many personal questions 6 10.5% 12.3%

I do not like the physical exam 0 0.0% 0.0%

I use drugs or alcohol 8 14.0% 15.8%

It is hard to get there (transportation) 7 12.3% 17.5%

Long waiting time to get an appointment 5 8.8% 8.8%

I do not have needed identification (ID)/my ID does not match who I am 2 3.5% 3.5%

Services are not in my language 0 0.0% 0.0%

I do not have legal status in the U.S. 0 0.0% 0.0%

I do not have money to pay 10 17.5% 22.8%

Other 5 8.8% 12.3%

Out-of-Care n = 57 (Answered No to Q4, Q5 AND Q6) Respondents were permitted to choose more than one.

Reasons for Dropping Out-of-Care Black/African-Americans who had left care at least six months in the past five years were asked why they dropped out-of-care. The three most frequent reasons given for not receiving medical care were:

 Drug or alcohol use (43% of which 27% using drugs and 16% using alcohol)

 It was hard to keep appointments (38%)

 Not feeling sick (33%).

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Table 4.50 Reasons for Dropping Out-of-Care

Black/African-American Men & Women Out-of-Care

Out-of-Care

Black/AA

Total Out-of-Care

Sample

In the past year, why was it hard for you to get HIV medical care? (Check all that apply) # %

%

It was hard to keep appointments 34 38.6% 32.3%

I did not feel sick 29 33.0% 28.1%

I was tired of taking medicines 28 31.8% 26.9%

I was using drugs 24 27.3% 26.3%

I did not have money 23 26.1% 24.6%

I needed a break 19 21.6% 19.8%

I was tired of going to the clinic 18 20.5% 18.6%

Other 17 19.3% 18.0%

It was hard to get to the clinic (transportation) 15 17.0% 16.8%

I was using alcohol 14 15.9% 13.8%

The appointments took too long 13 14.8% 12.6%

I did not need or want medical care 12 13.6% 11.4%

I moved and did not know where to go 9 10.2% 11.4%

The staff does not understand my culture 8 9.1% 5.4%

Staff does not understand my language 2 2.3% 1.8%

Out-of-Care n = 88 Respondents were permitted to choose more than one.

SERVICE NEEDS Black/African-Americans most frequently identified service needs range from dental care visits to medical case management. The top needs included:

 Dental visits

 HIV outpatient medical care

 Food bank

 Help paying for prescriptions/medicines

 Transportation to medical care

 Medical care from a specialist

 Primary medical care unrelated to HIV

 Emergency long-term rental assistance voucher

 Emergency financial assistance for rent/mortgage or utilities

 Medical case management

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In-care Black/African-American men and women included one different service in their top 10 service needs:

 Help paying for co-pays, deductibles for HIV medical care visits and medications. Out-of-care consumers’ top 10 needs included mental health counseling and employment services.

Table 4.51 Service Needs

Black/African-American Men & Women

In-Care Out-of-Care Total

Black/AA Total

Sample

From the list below, check the 5 services you need the most:

# % # % # % %

Dental Visits 143 56.5% 79 59.0% 222 57.4% 57.8%

HIV Outpatient Medical Care 137 54.2% 57 42.5% 194 50.1% 46.9%

Food Bank 120 47.4% 57 42.5% 177 45.7% 47.9%

Help paying for prescription medicines 80 31.6% 40 29.9% 120 31.0% 32.1%

Medical Care from a Specialist referred by your HIV medical provider

73 28.9% 32 23.9% 105 27.1% 25.3%

Transportation to Medical Care—Bus Pass/Van Service

71 28.1% 38 28.4% 109 28.2% 24.5%

Primary Medical Care for general medical care not related to HIV

55 21.7% 40 29.9% 95 24.5% 25.1%

Emergency Long-Term Rental Assistance (Voucher)

52 20.6% 33 24.6% 85 22.0% 20.5%

Emergency Financial Assistance for Rent/Mortgage or Utilities

59 23.3% 25 18.7% 84 21.7% 21.1%

Medical Case Management 56 22.1% 24 17.9% 80 20.7% 19.1%

Help paying for co-pays and deductibles for HIV medical care visits and medications

54 21.3% 23 17.2% 77 19.9% 19.8%

Mental Health Counseling 41 16.2% 29 21.6% 70 18.1% 18.9%

Employment Services 25 9.9% 28 20.9% 53 13.7% 14.5%

Nutritional Counseling 33 13.0% 16 11.9% 49 12.7% 12.2%

Transportation to Other Services 37 14.6% 12 9.0% 49 12.7% 11.0%

Education Services 17 6.7% 22 16.4% 39 10.1% 9.5%

Job Training Services 15 5.9% 23 17.2% 38 9.8% 9.2%

Non-Medical Case Management 25 9.9% 12 9.0% 37 9.6% 12.2%

If you have health insurance, help with continuing this insurance

23 9.1% 10 7.5% 33 8.5% 7.9%

Facility Based Housing (Assisted Living Facility) 22 8.7% 11 8.2% 33 8.5% 6.7%

Legal Services to help you work through a problem obtaining services/benefits, outline advance directives or establish guardianships

21 8.3% 8 6.0% 29 7.5% 9.3%

Outpatient Substance Abuse Treatment 8 3.2% 11 8.2% 19 4.9% 4.2%

Child Care while at a medical or other 8 3.2% 4 3.0% 12 3.1% 2.4%

Respite Care for Adults (Activities during day) 9 3.6% 2 1.5% 11 2.8% 2.2%

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In-Care Out-of-Care Total

Black/AA Total

Sample

From the list below, check the 5 services you need the most:

# % # % # % %

Early Intervention to help you get into HIV medical care

3 1.2% 5 3.7% 8 2.1% 2.2%

Respite Care for HIV positive children 2 0.8% 1 0.7% 3 0.8% 0.4%

Translation or Interpretation 0 0.0% 1 0.7% 1 0.3% 1.4%

In-Care n = 253; Out-of-Care n = 134; Combined In-Care n = 387 Respondents were permitted to choose more than one.

KEY INFORMANT INTERVIEWS Key informants provided the bulk of information regarding needs of priority populations. With regard to Black/African-Americans, the general view was that culturally relevant and appropriate services were important to keeping people in care – “Ask them who do you have sex with,” rather than “Are you gay, straight, etc.?” It is noted that the comments presented below represent the beliefs, opinions and experiences of those interviewed. Specific comments made about stigma and culture included:

 Breaking down the social determinants. There are high degrees of poverty, low educational attainment and high incarceration rates; all these are fundamental in driving the epidemic.

 Cultural bias still exists and we need to continue our efforts to culturally educate our providers.

 With the Black/African-American community there is a lot of stigma. Women

 Among women, domestic violence, intimate partner violence needs to be addressed.

 Since Black/African-American women primarily contact HIV through sex their needs are going to be on addressing sexual determinants and empowerment.

 Among men, how has their incarceration affected women in their relationships? Other Needs

 Access to health care and to a primary care provider.

 Information and education, and actual on-the-ground case management. FOCUS GROUP It should be noted that the comments presented below represent the beliefs, opinions and experiences of those interviewed.

 Black/African-American men need more Black/African-American men in the field to be able to relate to someone who looks like you.

 If the Black churches would accept that HIV exists and would start talking about it, we could help.

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RECOMMENDATIONS Black/African-Americans mirror the overall sample in terms of service needs, making general recommendations applicable. However, there appears to be a greater need for case management and counseling services to deal with social determinants and support needs of this population. Specific recommendations include: 1. Require annual cultural competence training to all staff receiving Ryan White funding. 2. Encourage medical and case management personnel to obtain training in identification of victims

of domestic violence and intimate partner violence. 3. Require agencies receiving Ryan White funding to ensure their staffs are culturally and

linguistically representative of the consumers they serve. 4. Support efforts to break down the stigma of HIV among Black/African-Americans and that

normalize testing, PrEP and healthy behaviors.

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HISPANIC/LATINO MEN AND WOMEN The consumer survey sample consisted of 113 Hispanic/Latinos3 living with HIV/AIDS, comprising 16% of the total sample. The Hispanic/Latino sample included 76 (67%) in-care consumers and 37 (33%) out-of- care consumers. This population is characterized by the highest increase in PLWH in the Dallas EMA from 2011 2015 of 34.8%. Hispanics/Latinos in the Dallas EMA had Hispanics/Latinos had the second highest DSHS unmet need in the Dallas EMA (23%). RESPONDENT OVERVIEW Demographics Hispanic/Latino respondents were 74% male, 20.4% female, and 6.2% other gender identity. The overall survey sample included 75% male, 23% female, and 2% other gender identity.

 In-care Hispanic/Latino respondents were 78% male and 16% female, and out-of-care Hispanic/Latino respondents were 65% male and 30% female.

Table 4.52

Gender Hispanic/Latino Men & Women

In-Care Out-of-Care Total Hispanic Total Sample

Gender Identity # % # % # % %

Male 59 77.6% 24 64.9% 83 73.5% 75.0%

Female 12 15.8% 11 29.7% 23 20.4% 22.8%

Transgender / Other Gender Identity 5 6.6% 2 5.4% 7 6.2% 2.2%

Total 76 100.0% 37 100.0% 113 100.0% 100.0%

In-Care n = 76; Out-of-Care n = 37; Combined In-Care/Out-of-Care n = 113

The age ranges of Hispanic/Latino respondents differ from those in the total sample with a larger percentage age 35-54.

 4% are youths ages 13–24 compared to 3% in the total sample.

 13% are 25-34 years old compared to 16% in the total sample.

 22% of Hispanics were between 35-44 years old compared to 20% of the total sample.

3 The consumer survey included an ethnicity question asking “Are you Hispanic/Latino?”, so this discussion includes consumers who self-designate as either “Hispanic or Latino.”

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Table 4.53 Age

Hispanic/Latino Men & Women

In-Care Out-of-Care Total

Hispanic Total

Sample

Age Cohort # % # % # % %

Age 13-24 3 3.9% 2 5.4% 5 4.4% 3.2%

Age 25-34 8 10.5% 7 18.9% 15 13.3% 16.2%

Age 35-44 15 19.7% 10 27.0% 25 22.1% 19.9%

Age 45-54 23 30.3% 15 40.5% 38 33.6% 30.4%

Age 55+ 23 30.3% 2 5.4% 25 22.1% 28.1%

Age Not Reported 4 5.3% 1 2.7% 5 4.4% 2.2%

Total 76 100.0% 37 100.0% 113 100.0% 100.0%

In-Care n = 76; Out-of-Care n = 37; Combined In Care/Out-of-Care n = 113

Transmission Mode Considering transmission mode as self-reported in the consumer survey, 50% of Hispanics/Latinos were MSM, 27% heterosexual contact, and 6% IDU. Hispanic respondents reported “unknown” or other” mode of transmission to a greater degree than found in the total survey, 22% vs. 18%.

 Comparing transmission mode of in-care and out-of-care Hispanics/Latinos,  In-care had a larger percentage reporting heterosexual transmission, 28% vs. 24%.  Out-of-care had a greater percentage reporting IDU transmission, 8% vs. 5%.  In-care and out-of-care Hispanics reported nearly identical percentage of MSM, 50% for

in-care vs. 49% for out-of-care.

County of Residence

 82% of Hispanic/Latino survey respondents were from Dallas County (82%). Six percent were from Denton County, and Cooke and Grayson Counties each had one respondent.

 A larger percentage of Hispanic respondents resided in Collin County, 6% vs. 3%. 8% of in-care Hispanic respondents were from that county.

Table 4.54

County of Residence Hispanic/Latino Men & Women

In-Care Out-of-Care Total

Hispanic Total

Sample

County # % # % # % %

Collin 6 7.9% 1 2.7% 7 6.2% 3.4%

Cooke 1 1.3% 0 0.0% 1 0.9% 0.4%

Dallas 61 80.3% 32 86.5% 93 82.3% 83.1%

Denton 7 9.2% 4 10.8% 11 9.7% 9.5%

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In-Care Out-of-Care Total

Hispanic Total

Sample

County # % # % # % %

Ellis 0 0.0% 0 0.0% 0 0.0% 0.1%

Fannin 0 0.0% 0 0.0% 0 0.0% 0.1%

Grayson 1 1.3% 0 0.0% 1 0.9% 3.2%

Henderson 0 0.0% 0 0.0% 0 0.0% 0.0%

Hunt 0 0.0% 0 0.0% 0 0.0% 0.1%

Kaufman 0 0.0% 0 0.0% 0 0.0% 0.0%

Navarro 0 0.0% 0 0.0% 0 0.0% 0.0%

Rockwall 0 0.0% 0 0.0% 0 0.0% 0.0%

Total 76 100.0% 37 100.0% 113 100.0% 100.0%

In-Care n = 76; Out-of-Care n = 37; Combined In-Care/Out-of-Care n = 113

Table 4.55

Transmission Mode Hispanic/Latino Men & Women

In-Care Out-of-Care Total

Hispanic Total

Sample

Transmission Mode # % # % # % %

MSM 38 50.0% 18 48.6% 56 49.6% 50.1%

IDU 4 5.3% 3 8.1% 7 6.2% 6.0%

MSM + IDU 4 5.3% 0 0.0% 4 3.5% 2.4%

Heterosexual 21 27.6% 9 24.3% 30 26.5% 31.9%

Do Not Know 6 7.9% 5 13.5% 11 9.7% 7.9%

Other 10 13.2% 4 10.8% 14 12.4% 9.6%

In-Care n = 76; Out-of-Care n = 37; Combined In-Care/Out-of-Care n = 113

Educational Attainment and Employment Educational attainment of Hispanics/Latinos was lower than that of the total survey sample.

 24% of Hispanic/Latinos did not complete high school, compared to 16% for the overall survey; this includes 21% of in-care and 30% of out-of-care Hispanic/Latinos.

 Hispanic/Latinos had similar percentage of high school graduates/GEDs as the total sample, 34% vs. 35%.

 37% of Hispanic/Latinos completed some college or graduate study, lower than 43% in the overall sample.

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Table 4.56 Educational Attainment

Hispanic/Latino Men & Women

In-Care Out-of-Care Total

Hispanic Total

Sample

Educational Attainment # % # % # % %

Eighth Grade or Less 2 2.6% 3 8.1% 5 4.4% 3.3%

Some High School 14 18.4% 8 21.6% 22 19.5% 12.9%

High School Graduate/GED 30 39.5% 8 21.6% 38 33.6% 34.9%

Technical or Trade School 2 2.6% 1 2.7% 3 2.7% 4.9%

Some College 18 23.7% 10 27.0% 28 24.8% 28.8%

Completed College 8 10.5% 6 16.2% 14 12.4% 10.3%

Graduate Education 0 0.0% 0 0.0% 0 0.0% 4.0%

Other 2 2.6% 1 2.7% 3 2.7% 0.9%

Total 76 100.0% 37 100.0% 113 100.0% 100.0%

In-Care n = 76; Out-of-Care n = 37; Combined In-Care/Out-of-Care n = 113

Only 4% of Hispanic/Latinos PLWHs served in the military, below the 6% in the total sample. A larger percentage of out-of-care Hispanics (8%) served in the military.

Table 4.57 Military Service

Hispanic/Latino Men & Women

In-Care Out-of-Care Total

Hispanic Total

Sample

Served in Military # % # % # % %

Yes 2 2.6% 3 8.1% 5 4.4% 5.9%

No 74 97.4% 33 89.2% 107 94.7% 93.5%

Do Not Want To Say 0 0.0% 1 2.7% 1 0.9% 0.6%

Total 76 100.0% 37 100.0% 113 100.0% 100.0%

In-Care n = 76; Out-of-Care n = 37; Combined In-Care/Out-of-Care n = 113

One-third (33%) of Hispanic/Latino are employed compared to the total sample (24%).

 26% of Hispanic/Latino in-care respondents report full-time or part-time work, and 46% of out- of-care respondents reported full-time or part-time employment status. This compares to 22% of in-care respondents with full or part time employment and 28% of out-of-care with full or part time employment in the total survey sample.

 67% of Hispanic/Latinos are not working compared to 76% of the total sample.

 A higher percentage of in-care Hispanic/Latino respondents reported not working (74%) than out-of-care respondents (54%).

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Table 4.58

Employment Status Hispanic/Latino Men & Women

In-Care Out-of-Care Total

Hispanic Total

Sample

Employment Status # % # % # % %

Work Full-Time 10 13.2% 13 35.1% 23 20.4% 13.3%

Work Part-Time 10 13.2% 4 10.8% 14 12.4% 11.0%

Not Working 56 73.7% 20 54.1% 76 67.3% 75.6%

Total 76 100.0% 37 100.0% 113 100.0% 100.0%

In-Care n = 76; Out-of-Care n = 37; Combined In-Care/Out-of-Care n = 113

Of the 76 Hispanic/Latinos who were not working:

 37% were on disability (below 45% of the total sample).

 15% indicate their health precludes them from working even though they are not on disability.

 28% were looking for jobs; 35% of whom were out-of-care compared to 25% of those in-care.

Table 4.59 Unemployed Status

Hispanic/Latino Men & Women

In-Care Out-of-Care Total

Hispanic Total

Sample

If You Are Not Working, Which Best Describes You?

# % # % # % %

I am a student 2 3.6% 0 0.0% 2 2.6% 3.4%

I am looking for a job 14 25.0% 7 35.0% 21 27.6% 23.0%

I am retired 6 10.7% 0 0.0% 6 7.9% 4.7%

I work as a volunteer 2 3.6% 0 0.0% 2 2.6% 3.2%

My health keeps me from working - I am not on disability

5 8.9% 6 30.0% 11 14.5% 14.8%

My health keeps me from working - I am on disability

21 37.5% 7 35.0% 28 36.8% 44.8%

Other 6 10.7% 0 0.0% 6 7.9% 6.1%

Total 56 100.0% 20 100.0% 76 100.0% 100.0%

In-Care n = 56; Out-of-Care n = 20; Combined In-Care/Out-of-Care n = 76

Income Incomes for Hispanic/Latinos are lower than the total sample. Sixty-two percent of Hispanic/Latinos earn less than $950 a month compared to the total sample (68%).

 The total sample has a higher percentage earning more than $1,901 per month (9%) than Hispanic/Latinos (6%).

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Table 4.60

Income Hispanic/Latino Men & Women

In-Care Out-of-Care Total

Hispanic Total

Sample

Monthly Income # % % % # % %

Less than $950 49 64.5% 21 56.8% 70 61.9% 68.1%

$950 - $1,900 23 30.3% 13 35.1% 36 31.9% 22.5%

$1,901 - $2,800 4 5.3% 2 5.4% 6 5.3% 6.7%

More than $2,800 0 0.0% 1 2.7% 1 0.9% 2.6%

Total 76 100.0% 37 100.0% 113 100.0% 100.0%

In-Care n = 76; Out-of-Care n = 37; Combined In-Care/Out-of-Care n = 113

Housing Situation Over half (56%) of Hispanic/Latino men and women report living “in an apartment/house/mobile home that I own or rent in my own name.”

 19% have permanent residency, relative to 14% in total sample.  16% in a parent or relative’s home.  3% in another person’s apartment or home.

 7% have a temporary residency situation, while 10% of the total sample has a temporary situation.  3.5% in a parent or relative’s home.  3.5% in another person’s apartment or home.

 Nearly 4% report homelessness, compared to 8% in the total survey.  2% on the street or in a car.  2% report living in a homeless shelter.

 5% report living in an assisted living facility.

Table 4.61 Housing Situation

Hispanic/Latino Men & Women

In-Care Out-of-Care Total

Hispanic/Latino Total

Sample

Where do you live now? (check only one) # % # % # % %

In an apartment/house/mobile home that I own or rent in my name

46 60.5% 17 45.9% 63 55.8% 52.2%

At my parent's or a relative's home-permanent 13 17.1% 5 13.5% 18 15.9% 8.3%

In a "supportive living" facility (Assisted Living Facility)

4 5.3% 2 5.4% 6 5.3% 7.3%

At another person's apartment/home-permanent 3 3.9% 0 0.0% 3 2.7% 5.9%

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In-Care Out-of-Care Total

Hispanic/Latino Total

Sample

Where do you live now? (check only one) # % # % # % %

At another person's apartment/home-temporary 0 0.0% 4 10.8% 4 3.5% 5.6%

At my parent's or a relative's home-temporary 1 1.3% 3 8.1% 4 3.5% 4.6%

Homeless (on the street or in car) 1 1.3% 1 2.7% 2 1.8% 4.0%

In a half-way house, transitional housing or treatment facility (drug or psychiatric)

3 3.9% 1 2.7% 4 3.5% 4.0%

Homeless Shelter 0 0.0% 2 5.4% 2 1.8% 3.6%

In a rooming or boarding house 2 2.6% 1 2.7% 3 2.7% 2.0%

Residential hospice facility or skilled nursing home 1 1.3% 0 0.0% 1 0.9% 0.1%

Domestic Violence Shelter 0 0.0% 0 0.0% 0 0.0% 0.0%

Other 2 2.6% 1 2.7% 3 2.7% 2.3%

Total 76 100.0% 37 100.0% 113 100.0% 100.0%

In-Care n = 76; Out-of-Care n = 37; Combined In-Care/Out-of-Care n = 113

Substance Use and Mental Health Disorders The consumer survey respondents were asked about current drug and alcohol use with the following results:

 Only four (4%) Hispanic respondents admitted to using IV drugs, with three being out-of-care.

 Nearly 65% refused to respond to the question compared to 60% of the total sample.

Table 4.62 Substance Abuse

Hispanic/Latino Men & Women

In-Care Out-of-Care Total

Hispanic Total

Sample

IV Drug Use in the Past Six Months # % # % # % %

Yes 1 1.3% 3 8.1% 4 3.5% 3.3%

No 25 32.9% 11 29.7% 36 31.9% 36.3%

No Response 50 65.8% 23 62.2% 73 64.6% 60.4%

Total 76 100.0% 37 100.0% 113 100.0% 100.0%

In-Care n = 76; Out-of-Care n = 37; Combined In-Care/Out-of-Care n = 113

Consumers were asked about drug use in the last six months:

 51% of Hispanic/Latino PLWH responded “Yes” to the use of alcohol or drugs compared to 56% overall.

 A higher percent (54%) of those using drugs or alcohol were out-of-care compared to in-care (50%).

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Table 4.63 Substance Use in the Last 6 Months

Hispanic/Latino Men & Women

In-Care Out-of-Care Total

Hispanic Total

Sample

Substance Use # % # % # % %

Have Used Drugs or Alcohol in Past 6 Months 38 50.0% 20 54.1% 58 51.3% 56.2%

No Drugs Listed Used 38 50.0% 17 45.9% 55 48.7% 43.8%

Total 76 100.0% 37 100.0% 113 100.0% 100.0%

In-Care n = 76; Out-of-Care n = 37; Combined In-Care/Out-of-Care n = 113

The most frequent substance used in the last six months was alcohol (74%) followed by marijuana (38%) and stimulants (24%).

 Alcohol use was mentioned more frequently by Hispanic/Latino respondents than by those in the total sample (74% vs 69%).

 A much higher percentage of out-of-care/returned to care respondents used stimulants (40%) compared to 16% of in-care respondents.

 Opioids and morphine were used by 15% of out-of-care respondents compared to 8% of in-care respondents.

 13% of in-care respondents used depressants compared to only 5% of out-of-care respondents.

Table 4.64 Substance Use in the Last 6 Months

Hispanic/Latino Men & Women

In-Care Out-of-Care Total

Hispanic Total

Sample

Substance Use # % # % # % %

Alcohol 27 71.1% 16 80.0% 43 74.1% 69.1%

Marijuana 13 34.2% 9 45.0% 22 37.9% 46.4%

Depressants 5 13.2% 1 5.0% 6 10.3% 10.2%

Ketamine/PCP 0 0.0% 1 5.0% 1 1.7% 0.3%

Hallucinogens 0 0.0% 0 0.0% 0 0.0% 1.0%

Opioids and Morphine 3 7.9% 3 15.0% 6 10.3% 11.2%

Stimulants 6 15.8% 8 40.0% 14 24.1% 19.9%

Steroids not prescribed by your doctor 1 2.6% 0 0.0% 1 1.7% 0.8%

Prescription painkillers not prescribed by your doctor 2 5.3% 1 5.0% 3 5.2% 6.1%

Inhalants 1 2.6% 1 5.0% 2 3.4% 2.6%

In-Care n = 38; Out-of-Care n = 20; Combined In-Care/Out-of-Care n = 58

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Respondents who indicated they used alcohol were asked if they used alcohol more than three times a week.

 35% responded positively, compared to 29% of the total sample.

Table 4.65 Alcohol Use

Hispanic/Latino Men & Women

In-Care Out-of-Care Total

Hispanic Total

Sample

Do you Drink Alcohol More Than 3 Times A

Week? # % # % # % %

Yes 9 33.3% 6 37.5% 15 34.9% 29.2%

No 18 66.7% 10 62.5% 28 65.1% 70.8%

Total 27 100.0% 16 100.0% 43 100.0% 100.0%

In-Care n = 27; Out-of-Care n = 16; Combined In-Care/Out-of-Care n = 43

Active substance abuse users were asked if they had thought about going to substance abuse treatment.

 30% responded positively, slightly greater than the total sample (28%).

 More out-of-care respondents (50%) had thought about getting into care than in-care respondents (18%).

Table 4.66

Considering Treatment Hispanic/Latino Men & Women

In-Care Out-of-Care Total

Hispanic Total

Sample

Have Thought About Seeking Substance Abuse Treatment

# % % % # % %

Yes 7 18.4% 10 50.0% 17 30.4% 28.4%

No 30 78.9% 9 45.0% 39 69.6% 71.6%

No Response 1 2.6% 1 5.0% 2 3.6% 1.3%

Total 38 100.0% 20 100.0% 56 100.0% 100.0%

In-Care n = 38; Out-of-Care n = 20; Combined In-Care/Out-of-Care n = 56

Almost 25% of Hispanic/Latino consumer survey respondents were diagnosed with depression compared to 30% overall.

 A slightly higher proportion of out-of-care consumers reported depression (27%) than those in- care (24%).

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Table 4.67 Depression Diagnosis

Hispanic/Latino Men & Women

In-Care Out-of-Care Total

Hispanic Total

Sample

Have You Received Medical Treatment for Depression in the Last 12 Months # %

% % # %

%

Yes 18 23.7% 10 27.0% 28 24.8% 29.7%

No 58 76.3% 27 73.0% 85 75.2% 70.3%

Total 76 100.0% 37 100.0% 113 100.0% 100.0%

In-Care n = 76; Out-of-Care n = 37; Combined In-Care/Out-of-Care n = 113

DIAGNOSIS AND REFERRAL FOR CARE Slight differences existed between diagnosis dates of Hispanic/Latino in-care and out-of-care/returned to care consumers, with out-of-care consumers being more recently diagnosed.

 More than 50% of consumers were diagnosed since 2005. This includes 65% of out-of-care consumers, and 44% of in-care consumers.

 Hispanic/Latino respondents tended to be diagnosed later than those of the total sample (50% vs. 47%).

Table 4.68

Year of Diagnosis Hispanic/Latino Men & Women

In-Care Out-of-Care Total

Hispanic Total

Sample

Year Diagnosed with HIV # % % % # % %

Before 1990 11 14.5% 2 5.4% 13 11.5% 11.8%

1990-1995 8 10.5% 4 10.8% 12 10.6% 12.9%

1996-1999 9 11.8% 3 8.1% 12 10.6% 11.3%

2000-2004 15 19.7% 4 10.8% 19 16.8% 16.5%

2005-2007 5 6.6% 3 8.1% 8 7.1% 9.0%

2008-2010 5 6.6% 6 16.2% 11 9.7% 11.8%

2011-2013 10 13.2% 9 24.3% 19 16.8% 11.6%

2014-2017 13 17.1% 5 13.5% 18 15.9% 14.1%

No Response or Unclear Response 0 0.0% 1 2.7% 1 0.9% 1.0%

Total 76 100.0% 37 100.0% 113 100.0% 100.0%

In-Care n = 76; Out-of-Care n = 37; Combined In-Care/Out-of-Care n = 113

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Differences were found in how quickly in-care and out-of-care Hispanic/Latino consumers access medical care.

 The percentage of Hispanic/Latino respondents who reported seeing a doctor within three months exceeded the total sample (32% vs. 26%).

 28% of in-care compared to 24% of out-of-care consumers reported seeing a doctor within one month.

 40% of in-care Hispanic/Latinos compared to 16% of out-of-care Hispanic/Latinos reported seeing a doctor within three months.

 16% of out-of-care compared to 11% of in-care Hispanic/Latinos reported seeing the doctor within 3-6 months of diagnosis.

 41% of out-of-care compared to 22% of in-care consumers waited more than six months to see a doctor.

Table 4.69

Care After Diagnosis Hispanic/Latino Men & Women

In-Care Out-of-Care Total

Hispanic Total

Sample

How Soon After Your Diagnosis Did You Go To See a Doctor About Your HIV?

# % # % # % %

In less than 1 month 21 27.6% 9 24.3% 30 26.5% 24.1%

In less than 3 months 30 39.5% 6 16.2% 36 31.9% 26.5%

Within 3 to 6 months 8 10.5% 6 16.2% 14 12.4% 16.6%

After more than 6 months 17 22.4% 15 40.5% 32 28.3% 28.8%

I have not received HIV medical care 0 0.0% 1 2.7% 1 0.9% 3.7%

No Response 0 0.0% 0 0.0% 0 0.0% 0.1%

Total 76 100.0% 37 100.0% 113 100.0% 100.0%

In-Care n = 76; Out-of-Care n = 37; Combined In-Care/Out-of-Care n = 113

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ACCESS TO HIV CARE FOR THE INCARCERATED Approximately 12% of Hispanic/Latino survey respondents were incarcerated for one month or more in the last 12 months. This was true for 12% of in-care consumers and 11% of out-of-care consumers.

Table 4.70 Incarceration

Hispanic/Latino Men & Women

In-Care Out-of-Care Total

Hispanic Total

Sample

Have you been In Jail or Prison for more than 1 month in the last 2 years? # %

# % #

% %

Yes 9 11.8% 4 10.8% 13 11.5% 12.5%

No 67 88.2% 33 89.2% 100 88.5% 87.5%

Total 76 100.0% 37 100.0% 113 100.0% 100.0%

In-Care n = 76; Out-of-Care n = 37; Combined In-Care/Out-of-Care n = 113

 92% of in-care Hispanic/Latino consumers received care while in prison compared to 81% in the sample.

 100% of out-of-care respondents received HIV medical care while in jail or prison. However, the small number of responses to this question (4) precludes generalization.

Table 4.71

HIV Care While Incarcerated Hispanic/Latino Men & Women

In-Care Out-of-Care

Total Hispanic

Total Sample

Did you receive HIV Medical Care While in Jail or Prison?

# % # % # % %

Yes 8 88.9% 4 100.0% 12 92.3% 80.5%

No 1 11.1% 0 0.0% 1 7.7% 19.5%

Total 9 100.0% 4 100.0% 13 100.0% 100.0%

In-Care n = 9; Out-of-Care n = 4; Combined In-Care/Out-of-Care n = 13

Previously incarcerated Hispanic/Latinos provided several reasons for not seeking care after their release. These included:

 “Afraid to tell others, I am HIV+.”

 “Could not find a place to live.”

 “Did not know where to go for medical care.”

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It should be noted that the small number of respondents preclude generalization of these responses.

Table 4.72 HIV Care After Incarceration

Hispanic/Latino Men & Women

In-Care Out-of-Care

Total Hispanic

Total Sample

After you were released, did any of the following stop you from getting HIV care? (Check all that apply)

# % % % # % %

Afraid to tell others I am HIV positive 3 33.3% 1 25.0% 4 30.8% 20.7%

Could not find a place to live 2 22.2% 1 25.0% 3 23.1% 13.8%

Did not know where to go for medical care 2 22.2% 1 25.0% 3 23.1% 12.6%

Did not know where to go for an intake or to get case management 0 0.0% 1 25.0% 1 7.7% 10.3%

Could not stop using drugs and/or alcohol 1 11.1% 1 25.0% 2 15.4% 10.3%

Fear of discrimination, harassment, denial of service, or violence 1 11.1% 1 25.0% 2 15.4% 5.7%

None of the above 5 55.6% 1 25.0% 6 46.2% 49.4%

In-Care n = 9; Out-of-Care n = 4; Combined In-Care/Out-of-Care n = 13

BARRIERS TO CARE In-Care Fifty-nine percent of in-care Hispanic/Latinos did not find it hard to get care compared to 57% of the total sample of consumers. The predominant barriers noted were:

 The amount of time it takes at the clinic (15%).

 Paperwork needed (11%).

 Not having transportation (11%). The rank order of responses is similar to those provided by the total in-care sample.

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Table 4.73

HIV Medical Care Potential Problems Hispanic/Latino Men & Women

In-Care

In the past year, why was it hard for you to get HIV medical care? (Check all that apply)

Hispanic In-Care

Total In- Care

Sample

% % %

It was not hard to get medical care 45 59.2% 56.5%

Amount of time it takes at the clinic 11 14.5% 15.1%

Paperwork needed 8 10.5% 12.9%

I do not have transportation so it's hard to get there 8 10.5% 12.0%

I cannot afford the co-pays, deductibles, and other costs of treatments and medicines 7 9.2% 9.4%

Sometimes I do not feel well enough to go to my appointment 7 9.2% 9.0%

Other 7 9.2% 8.8%

No weekend hours 6 7.9% 7.4%

I have to miss work to go to medical appointments 6 7.9% 7.2%

The time it takes to get an appointment 4 5.3% 5.7%

No evening hours (after 5 pm) 4 5.3% 4.8%

The clinic only treats HIV and no other medical conditions 3 3.9% 3.7%

The staff does not understand my culture 3 3.9% 2.6%

I do not feel mentally able to deal with the treatment 2 2.6% 1.8%

I am afraid of being seen at the clinic 1 1.3% 1.1%

The staff does not speak my language 1 1.3% 0.4%

It is too hard to follow the medical advice 0 0.0% 0.2%

I am in a domestic violence/sexual assault situation 0 0.0% 0.2%

Thirty-eight percent of out-of-care Hispanic/Latino respondents also indicated it was not hard to get care. For those who did find it hard, the following barriers were noted:

 38% cited stated it was not hard getting medical care.

 30% cited the paperwork needed.

 19% cited the amount of time it takes at the clinic.

 19% cited the unaffordability of co-pays, deductibles, and other costs of treatments and medicines.

 19% cited transportation as a barrier.

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Table 4.74 HIV Medical Care Potential Problems

Hispanic/Latino Men & Women Out-of-Care

In the past year, why was it hard for you to get HIV medical care? (Check all that apply)

Hispanic Out-of-Care

Total Out- of-Care Sample

# % %

It was not hard to get medical care 14 37.8% 35.4%

Paperwork needed 11 29.7% 20.8%

Amount of time it takes at the clinic 7 18.9% 20.4%

I do not have transportation so it's hard to get there 7 18.9% 15.8%

I cannot afford the co-pays, deductibles, and other costs of treatments and medicines 7 18.9% 15.8%

No evening hours (after 5 pm) 6 16.2% 14.6%

No weekend hours 5 13.5% 11.7%

The time it takes to get an appointment 4 10.8% 10.8%

Sometimes I do not feel well enough to go to my appointment 4 10.8% 10.4%

I am afraid of being seen at the clinic 4 10.8% 10.0%

I do not feel mentally able to deal with the treatment 4 10.8% 9.2%

It is too hard to follow the medical advice 4 10.8% 7.9%

I have to miss work to go to medical appointments 3 8.1% 7.9%

The clinic only treats HIV and no other medical conditions 2 5.4% 6.3%

The staff does not speak my language 2 5.4% 4.6%

Other 2 5.4% 3.3%

The staff does not understand my culture 1 2.7% 1.3%

I am in a domestic violence/sexual assault situation 1 2.7% 0.8%

In-Care n = 76; Out-of-Care n = 37; Combined In-Care/Out-of-Care n = 113

Twenty-six Hispanic/Latinos who were out-of-care during the last 12 months were asked to provide reasons for not being in care. Less than five respondents answered this questions, thereby precluding generalization or comparison with the total sample. The most common reasons for not being in care were:

 “I did not feel sick”.

 “I do not want to think about being HIV+”.

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Table 4.75 Why Are You Not Getting HIV Medical Care?

Hispanic/Latino Men & Women Out-of-Care

Why are you not getting HIV medical care? (Check all that apply)

Hispanic Out-of-Care

Total Sample Out-of-

Care

# % %

I do not feel sick 1 1.8% 59.6%

I do not need or want medical care 0 0.0% 10.5%

I do not want to think about being HIV positive 1 1.8% 29.8%

I am afraid to get medical care 0 0.0% 10.5%

It is too much trouble 0 0.0% 17.5%

I do not want to take medicines 0 0.0% 28.1%

Too much paperwork is needed 0 0.0% 8.8%

I am afraid to be seen at the clinic 0 0.0% 17.5%

The appointments cause problems with my job 0 0.0% 3.5%

The clinic asks too many personal questions 0 0.0% 12.3%

I do not like the physical exam 0 0.0% 0.0%

I use drugs or alcohol 0 0.0% 15.8%

It is hard to get there (transportation) 0 0.0% 17.5%

Long waiting time to get an appointment 0 0.0% 8.8%

I do not have needed identification (ID)/my ID does not match who I am 0 0.0% 3.5%

Services are not in my language 0 0.0% 0.0%

I do not have legal status in the U.S. 0 0.0% 0.0%

I do not have money to pay 0 0.0% 22.8%

Other 1 1.8% 12.3%

Out-of-Care n = 57 (Answered No to Q4, Q5 AND Q6)

Reasons for Dropping Out-of-Care The most frequent reason all out-of-care Hispanic/Latinos give for not receiving medical was “It was hard to get appointments”.

 A total of 31% were using drugs or alcohol (19% drugs and 12% alcohol).

 35% found it difficult to keep appointments

 27% were tired of taking medicine.

 27% needed a break.

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Table 4.76 Reasons for Dropping Out-of-Care

Hispanic/Latino Men & Women Out-of-Care

In the past year, why was it hard for you to get HIV medical care? (Check all that apply)

Hispanic Out-of-Care

Total Sample

Out-of-Care

# % %

It was hard to keep appointments 9 34.6% 32.3%

I was tired of taking medicines 7 26.9% 26.3%

I did not have money 6 23.1% 24.6%

I needed a break 7 26.9% 19.8%

I was tired of going to the clinic 5 19.2% 18.6%

I was using drugs 5 19.2% 28.1%

I did not feel sick 5 19.2% 26.9%

It was hard to get to the clinic (transportation) 5 19.2% 16.8%

I was using alcohol 3 11.5% 13.8%

The appointments took too long 3 11.5% 12.6%

I did not need or want medical care 2 7.7% 11.4%

I moved and did not know where to go 2 7.7% 11.4%

Other 1 3.8% 18.0%

The staff does not understand my culture 1 3.8% 5.4%

Staff does not understand my language 1 3.8% 1.8%

Out-of-Care n = 26

SERVICE NEEDS Hispanic/Latinos’ most frequently identified service needs range from dental care visits to employment services. The top needs include:

 Dental visits

 Food bank

 HIV outpatient medical care

 Help paying for prescriptions/medications

 Emergency financial assistance for rent/mortgage or utilities

 Emergency long term rental assistance

 Medical care from a specialist

 Transportation

 Primary medical care unrelated to HIV

 Employment services

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In-care Hispanic/Latinos included one different service in their top 10 service needs:

 Nutritional Counseling. Out-of-care Hispanic/Latinos included one different service in their top 10 service needs:

 Help paying for co-pays and deductibles for HIV medical care visits and medications.

Table 4.77 Service Needs

Hispanic/Latino Men & Women

From the list below, check the 5 services you need the most:

In-Care Out-of-Care Total

# % # % # %

Dental Visits 52 68.4% 22 59.5% 74 65.5%

Food Bank 40 52.6% 15 40.5% 55 48.7%

HIV Outpatient Medical Care 29 38.2% 14 37.8% 43 38.1%

Help paying for prescription medicines 25 32.9% 10 27.0% 35 31.0%

Emergency Financial Assistance for Rent/Mortgage or Utilities 17 22.4% 13 35.1% 30 26.5%

Medical Care from a Specialist referred by your HIV medical provider

19 25.0% 7 18.9% 26 23.0%

Transportation to Medical Care—Bus Pass/Van Service 13 17.1% 13 35.1% 26 23.0%

Emergency Long-Term Rental Assistance (Voucher) 19 25.0% 7 18.9% 26 23.0%

Primary Medical Care for general medical care not related to HIV

18 23.7% 7 18.9% 25 22.1%

Employment Services 15 19.7% 4 10.8% 19 16.8%

Help paying for co-pays and deductibles for HIV medical care visits and medications

11 14.5% 7 18.9% 18 15.9%

Non-Medical Case Management 12 15.8% 6 16.2% 18 15.9%

Nutritional Counseling 14 18.4% 4 10.8% 18 15.9%

Medical Case Management 11 14.5% 4 10.8% 15 13.3%

Legal Services to help you work through a problem obtaining services/benefits, outline advance directives or establish guardianships

9 11.8% 6 16.2% 15 13.3%

Transportation to Other Services 7 9.2% 5 13.5% 12 10.6%

Mental Health Counseling 7 9.2% 3 8.1% 10 8.8%

Education Services 3 3.9% 6 16.2% 9 8.0%

Translation or Interpretation 7 9.2% 2 5.4% 9 8.0%

Job Training Services 5 6.6% 3 8.1% 8 7.1%

Facility Based Housing (Assisted Living Facility) 4 5.3% 4 10.8% 8 7.1%

If you have health insurance, help with continuing this insurance 4 5.3% 2 5.4% 6 5.3%

Early Intervention to help you get into HIV medical care 3 3.9% 1 2.7% 4 3.5%

Outpatient Substance Abuse Treatment 1 1.3% 2 5.4% 3 2.7%

Respite Care for Adults (Activities during day) 1 1.3% 2 5.4% 3 2.7%

Child Care while at a medical or other 2 2.6% 0 0.0% 2 1.8%

Respite Care for HIV positive children 0 0.0% 0 0.0% 0 0.0%

In-Care n = 76; Out-of-Care n = 37; Combined In-Care/Out-of-Care n = 113

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KEY INFORMANT INTERVIEWS The comments presented below represent the beliefs, opinions and experiences of the participants. Key informants spoke of the issues surrounding the undocumented status of some Hispanic/Latino consumers and the need to focus on the family dynamics. Specific issues are outlined below. Immigration

 Security and fear of prosecution need to be relieved . . . the creation of a safe haven if one is going in for the prevention services and they are expected to engage in the continuum of care.

 Immigration barriers. Family-Focused Care

 They have a focus on family, and so incorporating some degree of focus on family would be a unique need for that population.

 Lots of myths around HIV risks and definitely a lot of stigma that builds around the dynamic of family.

 More emphasis on overall health, women’s health, and family health, and at the same time let them know about HIV testing.

Other Needs

 Education and information.

 Cultural barriers around language and bigger barriers around familiarity with the system of health care service delivery.

 Language services and the locations being accessible to their neighborhoods. We must be part of the community to dissolve the stigma associated with HIV.

 There needs to be more lay health care workers, peer support. FOCUS GROUP The comments presented below represent the beliefs, opinions and experiences of the participants.

 The front lines are not reflective of the people who are needing services.

 Females often want to talk to other females so they can relate more easily.

 Latinos are scared to get tested because they are undocumented, and afraid if they come back positive they will be deported.

 We need more bilingual staff in the HIV community because there is a lot of need in Latino communities with HIV testing, treatment and awareness that is not getting through because of the language barrier.

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RECOMMENDATIONS 1. Ensure that Ryan White-funded providers maintain adequate numbers of bilingual direct care

staff, and that all staff receive annual in-service training in cultural competence. 2. Ensure that continued education and outreach is made in Hispanic/Latino communities to reach

those at high risk. 3. Encourage collaboration with CBOs that serve large numbers of Hispanic/Latino clients in

outreach efforts with this community.

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MEN WHO HAVE SEX WITH MEN (MSM) The consumer survey included 349 men who identify having sex with men (MSM) as their mode of HIV transmission. This is 50% of all consumer survey responses. A similar percentage of MSM were out-of-care as compared to the overall survey sample.

 Specifically, 38% of MSM were out-of-care compared to 34% of all respondents. RESPONDENT OVERVIEW Demographics MSM were predominantly Black, African-American as reflected in the total sample as well. White/Caucasian, Hispanic/Latino and Multi-Race comprised approximately the same proportion collectively as Black/African-American MSM.

 48% of MSM were Black/African-American with a larger percentage out-of-care (51%) than in- care (46%).

 White/Caucasians comprised 33% of MSM, with similar in-care (33%) and out-of-care (32%) percentages.

 Hispanics were 16% of MSM, with 18% in-care and 14% out-of-care.

Table 4.78 Race/Ethnicity

MSM

In-Care Out-of-Care Total MSM Total

Sample

Race/Ethnicity # % # % # % %

Black/African-American 99 45.8% 68 51.1% 167 47.9% 55.5%

White/Caucasian 72 33.3% 42 31.6% 114 32.7% 24.7%

Hispanic/Latino (of any Race)

38 17.6% 18 13.5% 56 16.0% 16.2%

Multi-Racial 2 0.9% 4 3.0% 6 1.7% 2.0%

Native American 1 0.5% 0 0.0% 1 0.3% 0.4%

Asian 2 0.9% 0 0.0% 2 0.6% 0.4%

Other Race/Ethnicity 2 0.9% 1 0.8% 3 0.9% 0.7%

Total 216 100.0% 133 100.0% 349 100.0% 100.0%

In-Care n = 216; Out-of-Care n = 133; Combined In-Care/Out-of-Care n = 349

The age ranges of MSM respondents were similar but slightly younger than those for the overall survey sample.

 4% were youths ages 13–24 compared to 3% in the total sample.

 22% were 25-34 years old compared to 16% in the total sample.

 18% of MSM and 20% of the total sample were between 35-44 years old.

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 28% of MSM and 29% of the total sample were between 45 and 54 years old.

Table 4.79 Age

MSM

In-Care Out-of-Care Total MSM

Total Sample

Age Cohort # % # % # % %

Age 13-24 3 1.4% 11 8.3% 14 4.0% 3.2%

Age 25-34 37 17.1% 41 30.8% 78 22.3% 16.2%

Age 35-44 36 16.7% 27 20.3% 63 18.1% 19.9%

Age 45-54 64 29.6% 35 26.3% 99 28.4% 30.4%

Age 55+ 74 34.3% 17 12.8% 91 26.1% 28.1%

Age Not Reported 2 0.9% 2 1.5% 4 1.1% 2.2%

Total 216 100.0% 133 100.0% 349 100.0% 100.0%

In-Care n = 216; Out-of-Care n = 133; Combined In-Care/Out-of-Care n = 349

County of Residence MSM survey respondents were almost entirely from Dallas County. Collin, Cooke, Denton, Ellis, Fannin, Grayson, and Hunt Collin Counties were also represented.

 Collin, Grayson, and Denton had 10 or more respondents from the MSM community.

Table 4.80 County of Residence

MSM

In-Care Out-of-Care Total MSM

Total Sample

County # % # % # % %

Collin 6 2.8% 4 3.0% 10 2.9% 3.4%

Cooke 2 0.9% 0 0.0% 2 0.6% 0.4%

Dallas 180 83.3% 110 82.7% 290 83.1% 83.1%

Denton 19 8.8% 14 10.5% 33 9.5% 9.5%

Ellis 0 0.0% 1 0.8% 1 0.3% 0.1%

Fannin 1 0.5% 0 0.0% 1 0.3% 0.1%

Grayson 7 3.2% 4 3.0% 11 3.2% 3.2%

Henderson 0 0.0% 0 0.0% 0 0.0% 0.0%

Hunt 1 0.5% 0 0.0% 1 0.3% 0.1%

Kaufman 0 0.0% 0 0.0% 0 0.0% 0.0%

Navarro 0 0.0% 0 0.0% 0 0.0% 0.0%

Rockwall 0 0.0% 0 0.0% 0 0.0% 0.0%

Total 216 100.0% 133 100.0% 349 100.0% 100.0%

In-Care n = 216; Out-of-Care n = 133; Combined In-Care/Out-of-Care n = 349

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Educational Attainment More than half of MSM respondents graduated high school, technical or trade school. In-care MSM were somewhat better educated than out-of-care MSM. Likewise, educational attainment of in-care and out- of-care MSM was slightly higher to that of the total survey sample.

 A smaller percentage of MSM did not graduate high school (9%) than the overall sample (16%).

 17% of MSM completed college or had some graduate education, compared to 14% of the total sample have.

Table 4.81 Educational Attainment

MSM

In-Care Out-of-Care Total MSM

Total Sample

Educational Attainment # % # % # % %

Eighth Grade or Less 4 1.9% 1 0.8% 5 1.4% 3.3%

Some High School 14 6.5% 14 10.5% 28 8.0% 12.9%

High School Graduate/GED 69 31.9% 41 30.8% 110 31.5% 34.9%

Technical or Trade School 8 3.7% 10 7.5% 18 5.2% 4.9%

Some College 78 36.1% 47 35.3% 125 35.8% 28.8%

Completed College 32 14.8% 12 9.0% 44 12.6% 10.3%

Graduate Education 10 4.6% 6 4.5% 16 4.6% 4.0%

Other 1 0.5% 2 1.5% 3 0.9% 0.9%

Total 216 100.0% 133 100.0% 349 100.0% 100.0%

In-Care n = 216; Out-of-Care n = 133; Combined In-Care/Out-of-Care n = 349

Military Service Only 5% of MSM respondents served in the military, comparable to the total sample. Similar percentages were reported for in-care and out-of-care.

Table 4.82 Military Service

MSM

In-Care Out-of-Care Total MSM

Total Sample

Served in Military # % # % # % %

Yes 10 4.6% 6 4.5% 16 4.6% 5.9%

No 205 94.9% 127 95.5% 332 95.1% 93.5%

Do Not Want To Say 1 0.5% 0 0.0% 1 0.3% 0.6%

Total 216 100.0% 133 100.0% 349 100.0% 100.0%

In-Care n = 216; Out-of-Care n = 133; Combined In-Care/Out-of-Care n = 349

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Employment Status

MSM reported slightly higher percentages of full and part-time employment than that of the total sample.

 73% of MSM were not working compared to 76% of the total sample.

Table 4.83 Employment Status

MSM

In-Care Out-of-Care Total MSM

Total Sample

Employment Status # % # % # % %

Work Full-Time 29 13.4% 23 17.3% 52 14.9% 13.3%

Work Part-Time 21 9.7% 21 15.8% 42 12.0% 11.0%

Not Working 166 76.9% 89 66.9% 255 73.1% 75.6%

Total 216 100.0% 133 100.0% 349 100.0% 100.0%

In-Care n = 216; Out-of-Care n = 133; Combined In-Care/Out-of-Care n = 349

Of the 255 MSM who are not working:

 45% are on disability, similar to the 45% of the total sample.

 12% indicate their health precludes them from working even though they are not on disability.

 28% are looking for employment; 38% of whom are out-of-care compared to 22% of those in- care.

Table 4.84

Unemployment Status MSM

In-Care Out-of-Care Total MSM

Total Sample

If You Are Not Working, Which Best Describes You?

# % # % # % %

I am a student 4 2.4% 3 3.4% 7 2.7% 3.4%

I am looking for a job 36 21.7% 34 38.2% 70 27.5% 23.0%

I am retired 10 6.0% 1 1.1% 11 4.3% 4.7%

I work as a volunteer 4 2.4% 5 5.6% 9 3.5% 3.2%

My health keeps me from working - I am not on disability

21 12.7% 10 11.2% 31 12.2% 14.8%

My health keeps me from working - I am on disability

85 51.2% 30 33.7% 115 45.1% 44.8%

Other 6 3.6% 6 6.7% 12 4.7% 6.1%

Total 166 100.0% 89 100.0% 255 100.0% 100.0%

In-Care n = 166; Out-of-Care n = 89; Combined In-Care/Out-of-Care n = 255

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Income MSM incomes were somewhat higher than those in the total sample.

 63% of MSM earn less than $950 a month compared to the total sample (68%).

 13% of MSM earn more than $1,901 per month compared to 9% of the all respondents.

Table 4.85 Income MSM

In-Care Out-of-Care Total MSM

Total Sample

Monthly Income # % # % # % %

Less than $950 124 57.4% 94 70.7% 218 62.5% 68.1%

$950 - $1,900 61 28.2% 25 18.8% 86 24.6% 22.5%

$1,901 - $2,800 26 12.0% 10 7.5% 36 10.3% 6.7%

More than $2,800 5 2.3% 4 3.0% 9 2.6% 2.6%

Total 216 100.0% 133 100.0% 349 100.0% 100.0%

In-Care n = 216; Out-of-Care n = 133; Combined In-Care/Out-of-Care n = 349

Housing Situation While the majority of MSM (54%) report living “in an apartment/house/mobile home that I own or rent in my name”, there is variation among the remainder of this population.

 15% have permanent residency, compared to 14% of the total sample.  9% in a parent or relative’s home.  6% in another person’s apartment or home.

 12% have a temporary residency situation, compared to 10% of the total sample.  7% in a parent or relative’s home.  5% in another person’s apartment or home.

 Nearly 7% report homelessness, similar to 8% in the total survey.  5% on the street or in a car.  2% report living in a homeless shelter.

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Table 4.86 Housing Situation

MSM

In-Care Out-of-Care Total Total

Sample

Where do you live now? (check only one) # % # % # %

In an apartment/house/mobile home that I own or rent in my name

131 60.6% 56 42.1% 187 53.6% 52.2%

At my parent's or a relative's home-permanent 19 8.8% 11 8.3% 30 8.6% 8.3%

In a "supportive living" facility (Assisted Living Facility) 9 4.2% 10 7.5% 19 5.4% 7.3%

At another person's apartment/home-permanent 10 4.6% 12 9.0% 22 6.3% 5.9%

At another person's apartment/home-temporary 9 4.2% 15 11.3% 24 6.9% 5.6%

At my parent's or a relative's home-temporary 10 4.6% 8 6.0% 18 5.2% 4.6%

Homeless (on the street or in car) 8 3.7% 8 6.0% 16 4.6% 4.0%

In a half-way house, transitional housing or treatment facility (drug or psychiatric)

9 4.2% 5 3.8% 14 4.0% 4.0%

Homeless Shelter 5 2.3% 2 1.5% 7 2.0% 3.6%

In a rooming or boarding house 2 0.9% 3 2.3% 5 1.4% 2.0%

Residential hospice facility or skilled nursing home 1 0.5% 0 0.0% 1 0.3% 0.1%

Domestic Violence Shelter 0 0.0% 0 0.0% 0 0.0% 0.0%

Other 3 1.4% 3 2.3% 6 1.7% 2.3%

Total 216 100.0% 133 100.0% 349 100.0% 100.0%

In-Care n = 216; Out-of-Care n = 133; Combined In-Care/Out-of-Care n = 349

Substance Use and Mental Health Disorders Consumers were asked about drug use in the last six months and responded as follows.

 With regard to the use of alcohol or drugs, 63% of MSM responded “Yes.”  A higher percent (70%) of those using drugs or alcohol were out-of-care compared to in-

care (59%).

Table 4.87 Substance Use in the Last 6 Months

MSM

In-Care Out-of-Care Total MSM

Total Sample

Substance Use # % # % # % %

Have Used Drugs or Alcohol in Past 6 Months 127 58.8% 93 69.9% 220 63.0% 56.2%

No Drugs Listed Used 89 41.2% 40 30.1% 129 37.0% 43.8%

Total 216 100.0% 133 100.0% 349 100.0% 100.0%

In-Care n = 216; Out-of-Care n = 133; Combined In-Care/Out-of-Care n = 349

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The survey asked about injecting (IV) drug use with the following results.

 Over 4% of MSM respondents admitted to injecting drugs, one percentage point above the overall survey sample results.

 Nearly 8% of out-of-care MSM reported IV drug use.

 Nearly 58% refused to respond to the question.

Table 4.88 IV Drug Use

MSM

In-Care Out-of-Care Total MSM

Total Sample

IV Drug Use # % # % # % %

Yes 5 2.3% 10 7.5% 15 4.3% 3.3%

No 88 40.7% 45 33.8% 133 38.1% 36.3%

No Response 123 56.9% 78 58.6% 201 57.6% 60.4%

Total 216 100.0% 133 100.0% 349 100.0% 100.0%

In-Care n = 216; Out-of-Care n = 133; Combined In-Care/Out-of-Care n = 349

When asked about recent substance use, most frequent substance used among MSM was alcohol (74%) followed by marijuana (49%) and stimulants (23%). In nearly every case, MSM usage was proportionately greater than the total sample.

 A higher percentage of out-of-care respondents used stimulants (26%) compared to 21% of in- care respondents.

 Opioids and morphine were used by 12% of in-care respondents compared to 7% of out-of-care respondents.

 11% of in-care respondents used depressants compared to 9% of out-of-care respondents.

Table 4.89 Substance Use in the Last 6 Months

MSM

In-Care Out-of-Care Total MSM

Total Sample

Substance Use # % # % # % %

Alcohol 90 70.9% 73 78.5% 163 74.1% 69.1%

Marijuana 52 40.9% 55 59.1% 107 48.6% 46.4%

Depressants 14 11.0% 8 8.6% 22 10.0% 10.2%

Ketamine/PCP 0 0.0% 0 0.0% 0 0.0% 0.3%

Hallucinogens 0 0.0% 2 2.2% 2 0.9% 1.0%

Opioids and Morphine 15 11.8% 6 6.5% 21 9.5% 11.2%

Stimulants 27 21.3% 24 25.8% 51 23.2% 19.9%

Steroids not prescribed by your doctor 0 0.0% 0 0.0% 0 0.0% 0.8%

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In-Care Out-of-Care Total MSM

Total Sample

Substance Use # % # % # % %

Prescription painkillers not prescribed by your doctor 7 5.5% 7 7.5% 14 6.4% 6.1%

Inhalants 1 0.8% 5 5.4% 6 2.7% 2.6%

In-Care n = 127; Out-of-Care n = 93; Combined In-Care/Out-of-Care n = 220. Respondents were permitted to choose more than one.

MSM respondents who indicated they used alcohol were asked if they used it more than three times a week.

 34% responded positively, which is higher than the percentage reported by all sample respondents (29%).

Table 4.90

Alcohol Use MSM

Do you Drink Alcohol More Than 3 Times A Week?

In-Care Out-of-Care Total MSM

Total Sample

# % # % # % %

Yes 24 26.7% 32 43.8% 56 34.4% 29.2%

No 66 73.3% 41 56.2% 107 65.6% 70.8%

Total 90 100.0% 73 100.0% 163 100.0% 100.0%

In-Care n = 90; Out-of-Care n = 73; Combined In-Care/Out-of-Care n = 163

Active substance abuse users were asked if they had thought about going to substance abuse treatment.

 28% responded positively.

 More out-of-care respondents (36%) had thought about getting into care than in-care respondents (22%).

Table 4.91 Considering Treatment

MSM

In-Care Out-of-Care Total MSM

Total Sample

Have Thought About Seeking Substance Abuse Treatment # % # % # % %

Yes 28 22.0% 33 35.5% 61 27.7% 28.4%

No 97 76.4% 57 61.3% 154 70.0% 71.6%

No Response 2 1.6% 3 3.2% 5 2.3% 1.3%

Total 127 100.0% 93 100.0% 220 100.0% 100.0%

In-Care n = 127; Out-of-Care n = 93; Combined In-Care/Out-of-Care n = 220

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Almost 29% of MSM consumer survey respondents had been diagnosed with depression.

 A slightly higher proportion of in-care consumers reported depression (31%) than those out-of- care (26%).

Table 4.92

Depression Diagnosis MSM

Have You Received Medical Treatment for Depression in the Last 12 Months

In-Care Out-of-Care Total MSM

Total Sample

# % # % # % %

Yes 66 30.6% 34 25.6% 100 28.7% 29.7%

No 150 69.4% 99 74.4% 249 71.3% 70.3%

Total 216 100.0% 133 100.0% 349 100.0% 100.0%

In-Care n = 216; Out-of-Care n = 133; Combined In-Care/Out-of-Care n = 349

DIAGNOSIS AND REFERRAL FOR CARE MSM respondents reported slightly higher percentages of long-term survivorship and smaller percentages of recent diagnosis than the overall sample.

 30% of MSM were diagnosed before 1995 compared to 25% for overall respondents.

 MSM diagnosed after 2010 represent 30% of respondents, while 26% of the total sample was diagnosed after 2010.

Table 4.93 Year of Diagnosis

MSM

Year Diagnosed with HIV In-Care Out-of-Care Total MSM

Total Sample

# % # % # % %

Before 1990 41 19.0% 11 8.3% 52 14.9% 11.8%

1990-1995 38 17.6% 13 9.8% 51 14.6% 12.9%

1996-1999 17 7.9% 9 6.8% 26 7.4% 11.3%

2000-2004 27 12.5% 16 12.0% 43 12.3% 16.5%

2005-2007 15 6.9% 17 12.8% 32 9.2% 9.0%

2008-2010 25 11.6% 14 10.5% 39 11.2% 11.8%

2011-2013 21 9.7% 23 17.3% 44 12.6% 11.6%

2014-2017 29 13.4% 30 22.6% 59 16.9% 14.1%

No Response or Unclear Response 3 1.4% 0 0.0% 3 0.9% 1.0%

Total 216 100.0% 133 100.0% 349 100.0% 100.0%

In-Care n = 216; Out-of-Care n = 133; Combined In-Care/Out-of-Care n = 349

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Differences existed in how quickly in-care and out-of-care MSM consumers access medical care.

 24% of in-care compared to 19% of out-of-care consumers reported seeing a doctor within one month.

 29% of in-care MSM compared to 18% of out-of-care MSM reported seeing a doctor within three months.

 16% of in-care compared to 17% of out-of-care MSM reported seeing the doctor within 3-6 months of diagnosis.

 31% of in-care compared to 35% of out-of-care consumers waited more than six months to see a doctor.

Table 4.94

Care After Diagnosis MSM

How Soon After Your Diagnosis Did You Go to See a Doctor About Your HIV?

In-Care Out-of-Care Total MSM

Total Sample

# % # % # % %

In less than 1 month 52 24.1% 25 18.8% 77 22.1% 24.1%

In less than 3 months 63 29.2% 24 18.0% 87 24.9% 26.5%

Within 3 to 6 months 35 16.2% 23 17.3% 58 16.6% 16.6%

After more than 6 months 66 30.6% 46 34.6% 112 32.1% 28.8%

I have not received HIV medical care 0 0.0% 14 10.5% 14 4.0% 3.7%

No Response 0 0.0% 1 0.8% 1 0.3% 0.1%

Total 216 100.0% 133 100.0% 349 100.0% 100.0%

In-Care n = 216; Out-of-Care n = 133; Combined In-Care/Out-of-Care n = 349

ACCESS TO HIV CARE FOR THE INCARCERATED Approximately 12% of MSM survey respondents were incarcerated for one month or more in the last 12 months. This was true for 14% of out-of-care consumers and 12% of in-care consumers.

Table 4.95 Incarceration

MSM

Have you been In Jail or Prison for more than 1 month in the last 2 years?

In-Care Out-of-Care Total MSM

Total Sample

# % # % # % %

Yes 25 11.6% 18 13.5% 43 12.3% 12.5%

No 191 88.4% 115 86.5% 306 87.7% 87.5%

Total 216 100.0% 133 100.0% 349 100.0% 100.0%

In-Care n = 216; Out-of-Care n = 133; Combined In-Care/Out-of-Care n = 349

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Seventy-six percent of in-care MSM consumers received care while in prison compared to 67% of out-of- care respondents.

 This compares to 80% of in-care consumers in the total sample who received HIV medical care while in jail or prison, and 73% of out-of-care who received care in prison.

Table 4.96

HIV Care While Incarcerated MSM

Did you receive HIV Medical Care While in Jail or Prison?

In-Care Out-of-Care Total MSM

Total Sample

# % # % # % %

Yes 19 76.0% 12 66.7% 31 72.1% 80.5%

No 6 24.0% 6 33.3% 12 27.9% 19.5%

Total 25 100.0% 18 100.0% 43 100.0% 100.0%

In-Care n = 25; Out-of-Care n = 18; Combined In-Care/Out-of-Care n = 43

Previously incarcerated MSM provided a number of reasons for not seeking care after their release. More than half cited at least one reason for not seeking care. They included:

 “Could not find place to live”

 “Did not know where to go for medical care.”

 “Afraid to tell others, I am HIV+.”

 “Did not know where to go for an intake or to get case management.”

Table 4.97 HIV Care After Incarceration

MSM

After you were released, did any of the following stop you from getting HIV care? (Check all that apply)

In-Care Out-of-Care Total MSM

Total Sample

# % # % # % %

Afraid to tell others I am HIV positive 3 12.0% 3 16.7% 6 14.0% 20.7%

Could not find a place to live 4 16.0% 4 22.2% 8 18.6% 13.8%

Did not know where to go for medical care 5 20.0% 3 16.7% 8 18.6% 12.6%

Did not know where to go for an intake or to get case management 1 4.0% 5 27.8% 6 14.0% 10.3%

Could not stop using drugs and/or alcohol 1 4.0% 4 22.2% 5 11.6% 10.3%

Fear of discrimination, harassment, denial of service, or violence 1 4.0% 2 11.1% 3 7.0% 5.7%

None of the above 17 68.0% 4 22.2% 21 48.8% 49.4%

In-Care n = 25; Out-of-Care n = 18; Combined In-Care/Out-of-Care n = 43

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BARRIERS TO CARE In-Care Fifty-seven percent of in-care MSM did not find it hard to get care equal to the total sample of consumers. The three highest rated problems were:

 “The amount of time it takes at the clinic.”

 “Paperwork needed.”

 “I do not have transportation so it’s hard to get care.”

Table 4.98 HIV Medical Care Potential Problems

MSM In-Care

In the past year, why was it hard for you to get HIV medical care? (Check all that apply)

In-Care MSM

Total In-Care Sample

# % %

It was not hard to get medical care 121 56.0% 56.5%

Amount of time it takes at the clinic 37 17.1% 15.1%

Paperwork needed 31 14.4% 12.9%

I do not have transportation so it's hard to get there 30 13.9% 12.0%

The time it takes to get an appointment 24 11.1% 9.4%

I cannot afford the co-pays, deductibles, and other costs of treatments and medicines 22 10.2% 9.0%

No weekend hours 21 9.7% 8.8%

No evening hours (after 5 pm) 21 9.7% 7.4%

I have to miss work to go to medical appointments 20 9.3% 7.2%

Other 11 5.1% 5.7%

Sometimes I do not feel well enough to go to my appointment 8 3.7% 4.8%

I am afraid of being seen at the clinic 7 3.2% 3.7%

I do not feel mentally able to deal with the treatment 3 1.4% 2.6%

The clinic only treats HIV and no other medical conditions 2 0.9% 1.8%

The staff does not understand my culture 2 0.9% 1.1%

I am in a domestic violence/sexual assault situation 2 0.9% 0.4%

The staff does not speak my language 1 0.5% 0.2%

It is too hard to follow the medical advice 0 0.0% 0.2%

In-Care n = 216; Out-of-Care n = 133; Combined In-Care/Out-of-Care n = 349

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One-third of the out-of-care MSM also indicated it was not hard to get care. For those who did find it hard, the following barriers were noted:

 23% cited the paperwork needed.

 18% cited the amount of time it takes at the clinic.  17% do not have transportation.  17% cannot afford the co-pays, deductibles, and other costs of treatments and medicines.

Table 4.99 HIV Medical Care Potential Problems

MSM Out-of-Care

In the past year, why was it hard for you to get HIV medical care? (Check all that apply)

Out-of-Care MSM

Total Out-of-

Care Sample

# % %

It was not hard to get medical care 44 33.1% 35.4%

Paperwork needed 30 22.6% 20.8%

Amount of time it takes at the clinic 24 18.0% 20.4%

I do not have transportation so it's hard to get there 22 16.5% 15.8%

I cannot afford the co-pays, deductibles, and other costs of treatments and medicines 22 16.5% 15.8%

The time it takes to get an appointment 15 11.3% 14.6%

No evening hours (after 5 pm) 15 11.3% 11.7%

No weekend hours 14 10.5% 10.8%

I have to miss work to go to medical appointments 13 9.8% 10.4%

I do not feel mentally able to deal with the treatment 12 9.0% 10.0%

Sometimes I do not feel well enough to go to my appointment 10 7.5% 9.2%

Other 9 6.8% 7.9%

I am afraid of being seen at the clinic 8 6.0% 7.9%

It is too hard to follow the medical advice 7 5.3% 6.3%

The clinic only treats HIV and no other medical conditions 4 3.0% 4.6%

The staff does not understand my culture 3 2.3% 3.3%

I am in a domestic violence/sexual assault situation 1 0.8% 1.3%

The staff does not speak my language 1 0.8% 0.8%

In-Care n = 216; Out-of-Care n = 133; Combined In-Care/Out-of-Care n = 349. Respondents were permitted to choose more than one.

Reason for Not Getting Care Fifty-seven MSM who were out-of-care during the last 12 months were asked to provide reasons for not being in care. The most common reasons for not being in care were:

 “I did not feel sick”

 “I do not want to think about being HIV+”

 “I do not have money to pay”.

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 “It is hard to get there (transportation).”

Table 4.100 Why Are You Not Getting HIV Medical Care?

MSM Out-of-Care

Why are you not getting HIV medical care? (Check all that apply) Out-of-Care MSM

Total Out-of-

Care Sample

# % %

I do not feel sick 20 35.1% 59.6%

I do not need or want medical care 4 7.0% 10.5%

I do not want to think about being HIV positive 9 15.8% 29.8%

I am afraid to get medical care 3 5.3% 10.5%

It is too much trouble 5 8.8% 17.5%

I do not want to take medicines 4 7.0% 28.1%

Too much paperwork is needed 2 3.5% 8.8%

I am afraid to be seen at the clinic 4 7.0% 17.5%

The appointments cause problems with my job 2 3.5% 3.5%

The clinic asks too many personal questions 4 7.0% 12.3%

I do not like the physical exam 0 0.0% 0.0%

I use drugs or alcohol 5 8.8% 15.8%

It is hard to get there (transportation) 6 10.5% 17.5%

Long waiting time to get an appointment 2 3.5% 8.8%

I do not have needed identification (ID)/my ID does not match who I am 0 0.0% 3.5%

Services are not in my language 0 0.0% 0.0%

I do not have legal status in the U.S. 0 0.0% 0.0%

I do not have money to pay 7 12.3% 22.8%

Other 4 7.0% 12.3%

Out-of-Care n = 57 (Answered No to Q4, Q5 AND Q6). Respondents were permitted to choose more than one.

Reasons for Dropping Out-of-Care The three most frequent reasons out-of-care MSM give for dropping out-of-care were:

 Using drugs or alcohol (45%); 30% drugs and 15% alcohol.

 Difficult to keep appointments (28%).

 Did not feel sick (27%). Reasons largely mirrored those of the total sample.

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Table 4.101

Reasons for Dropping Out-of-Care MSM

Out-of-Care

In the past year, why was it hard for you to get HIV medical care? (Check all that apply)

Out-of-Care MSM

Total Out-of-Care

Sample

# % %

It was hard to keep appointments 27 28.4% 32.3%

I was using drugs 28 29.5% 28.1%

I did not feel sick 26 27.4% 26.9%

I was tired of taking medicines 25 26.3% 26.3%

I did not have money 24 25.3% 24.6%

I needed a break 17 17.9% 19.8%

I was tired of going to the clinic 14 14.7% 18.6%

Other 15 15.8% 18.0%

It was hard to get to the clinic (transportation) 13 13.7% 16.8%

I was using alcohol 14 14.7% 13.8%

The appointments took too long 8 8.4% 12.6%

I did not need or want medical care 14 14.7% 11.4%

I moved and did not know where to go 9 9.5% 11.4%

The staff does not understand my culture 3 3.2% 5.4%

Staff does not understand my language 2 2.1% 1.8%

Out-of-Care n = 95. Respondents were permitted to choose more than one.

SERVICE NEEDS MSM most frequently identified service needs range from dental care visits to transportation to care. The top needs include:

 Dental visits

 Food bank

 HIV outpatient medical care

 Help paying for prescriptions/medications

 Primary medical care unrelated to HIV

 Medical care from a specialist

 Transportation to medical care

 Help paying for co-pays, deductibles for HIV medical care visits and medications

 Emergency long-term rental assistance voucher

 Emergency financial assistance for rent/mortgage or utilities

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Out-of-care MSM included two different services in their top 10 service needs:

 Mental health counseling

 Employment services Table 4.102

Service Needs MSM

From the list below, check the 5 services you need the most:

In-Care Out-of-Care Total MSM

Total Sample

# % # % # % %

Dental Visits 130 60.2% 77 57.9% 207 59.3% 57.8%

Food Bank 116 53.7% 52 39.1% 168 48.1% 47.9%

HIV Outpatient Medical Care 95 44.0% 56 42.1% 151 43.3% 46.9%

Help paying for prescription medicines 73 33.8% 43 32.3% 116 33.2% 32.1%

Primary Medical Care for general medical care not related to HIV

49 22.7% 35 26.3% 84 24.1% 25.1%

Transportation to Medical Care—Bus Pass/Van Service 48 22.2% 35 26.3% 83 23.8% 24.5%

Medical Care from a Specialist referred by your HIV medical provider

57 26.4% 26 19.5% 83 23.8% 25.3%

Help paying for co-pays and deductibles for HIV medical care visits and medications

56 25.9% 27 20.3% 83 23.8% 19.8%

Emergency Long-Term Rental Assistance (Voucher) 45 20.8% 30 22.6% 75 21.5% 20.5%

Emergency Financial Assistance for Rent/Mortgage or Utilities

55 25.5% 19 14.3% 74 21.2% 21.1%

Mental Health Counseling 38 17.6% 31 23.3% 69 19.8% 18.9%

Employment Services 34 15.7% 29 21.8% 63 18.1% 14.5%

Medical Case Management 39 18.1% 23 17.3% 62 17.8% 19.1%

Non-Medical Case Management 28 13.0% 19 14.3% 47 13.5% 12.2%

Nutritional Counseling 30 13.9% 13 9.8% 43 12.3% 12.2%

Legal Services to help you work through a problem obtaining services/benefits, outline advance directives or establish guardianships

24 11.1% 12 9.0% 36 10.3% 9.3%

Education Services 16 7.4% 18 13.5% 34 9.7% 9.5%

Job Training Services 14 6.5% 20 15.0% 34 9.7% 9.2%

Transportation to Other Services 20 9.3% 13 9.8% 33 9.5% 11.0%

If you have health insurance, help with continuing this insurance

23 10.6% 6 4.5% 29 8.3% 7.9%

Facility Based Housing (Assisted Living Facility) 15 6.9% 9 6.8% 24 6.9% 6.7%

Outpatient Substance Abuse Treatment 6 2.8% 8 6.0% 14 4.0% 4.2%

Respite Care for Adults (Activities during day) 7 3.2% 2 1.5% 9 2.6% 2.2%

Early Intervention to help you get into HIV medical care 3 1.4% 4 3.0% 7 2.0% 2.2%

Translation or Interpretation 2 0.9% 1 0.8% 3 0.9% 1.4%

Respite Care for HIV positive children 1 0.5% 1 0.8% 2 0.6% 0.4%

Child Care while at a medical or other 1 0.5% 0 0.0% 1 0.3% 2.4%

In-Care n = 216; Out-of-Care n = 133; Combined In-Care/Out-of-Care n = 349. Respondents were permitted to choose more than one.

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INTERVIEWS WITH KEY INFORMANTS The comments presented below represent the beliefs, opinions and experiences of the key informants interviewed. Key informants were asked what services MSMs needed. Their responses included:

 Education regarding high risk behaviors and condom use.

 Create awareness. Some men don’t know how they transmit the disease.

 Prevention and care efforts have to intersect with the media MSM use to interact with each other on a sexual level (dating apps, social media, etc.).

 Agencies need to nurture them and allow them the freedom to make mistakes and still be accepted.

 Agencies must go to all types of events.

 We need more cultural competency to understand this community and diversify our staff to look more like the community, because if you don’t there will be no change.

PLANNING COUNCIL FOCUS GROUP The comments presented below represent the beliefs, opinions and experiences of the participants interviewed.

 The front lines are not necessarily reflective of the people who need services. So, I think more diversification of staff would be a huge help in making sure target populations get linked to care.

Also see key informant and focus group discussions in the section on African-Americans and Hispanics. RECOMMENDATIONS 1. MSMs in the Dallas Planning Area can be stratified by age, race/ethnicity, etc. Priority populations

include African-American MSMs, Hispanic MSMs, and young MSMs. Each group displays some differences by virtue of their culture.

 Targeted approaches should be developed for each priority population cited above.

 Provider collaboration will be necessary to expand targeted approaches to various populations and to share best practices.

 Support providers who successfully use cultural competency training, peer support, and patient navigation to enhance their success in linking and maintaining PLWH in care.

2. Ensure that all providers employ direct care personnel who reflect the characteristics of the target

population.

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TRANSGENDER PERSONS The consumer survey sample was comprised of 15 Transgender persons living with HIV/AIDS. This is 2% of the survey sample. The Transgender sample included 10 (77%) in-care consumers and 5 (33%) out-of- care consumers. The size and characteristics of Transgender PLWH is largely undetermined (Epidemiology data is recorded by sex at birth. ARIES data documented 69 (0.7%) clients identified as Transgender). Since the sample size does not allow for generalizations about this population, the data are presented for informational purposes only. RESPONDENT OVERVIEW Demographics One-third of transgender respondents identified as Transfemale or Transwoman; over one-quarter identified as Trans or Transgender, and one-fifth identified as Feminine-identified male.

Table 4.103 Gender Identity

Transgender

In-Care Out-of-Care Total

Do you identify as: # % # % # %

Transmale or Transman 2 20.0% 0 0.0% 2 13.3%

Transfemale or Transwoman 3 30.0% 2 40.0% 5 33.3%

Trans or Transgender 2 20.0% 2 40.0% 4 26.7%

Genderqueer 1 10.0% 0 0.0% 1 6.7%

Dual or Multi-Gender 0 0.0% 0 0.0% 0 0.0%

Agender or Neutrois 0 0.0% 0 0.0% 0 0.0%

Masculine-Identified Female 0 0.0% 0 0.0% 0 0.0%

Feminine-Identified Male 2 20.0% 1 20.0% 3 20.0%

Do Not Want to Say 0 0.0% 0 0.0% 0 0.0%

Total 10 100.0% 5 100.0% 15 100.0%

In-Care n = 10; Out-of-Care n = 5; Combined In-Care/Out-of-Care n = 15

Hispanic/Latino was the racial/ethnic category with the highest number of Transgender respondents (47%), followed by Black/African-American (40%), and White/Caucasian (13%).

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Table 4.104 Race/Ethnicity Transgender

In-Care Out-of-Care Total

Transgender Total

Sample

Race/Ethnicity # % # % # % %

Black/African-American 3 30.0% 3 60.0% 6 40.0% 55.5%

White/Caucasian 2 20.0% 0 0.0% 2 13.3% 24.7%

Hispanic/Latino (of any Race) 5 50.0% 2 40.0% 7 46.7% 16.2%

Multi-Racial 0 0.0% 0 0.0% 0 0.0% 2.0%

Native American 0 0.0% 0 0.0% 0 0.0% 0.4%

Asian 0 0.0% 0 0.0% 0 0.0% 0.4%

Other Race/Ethnicity 0 0.0% 0 0.0% 0 0.0% 0.7%

Total 10 100.0% 5 100.0% 15 100.0% 100.0%

In-Care n = 5; Out-of-Care n = 3; Combined In-Care/Out-of-Care n = 8

Thirteen percent of Transgender respondents were 13-24, far younger than those 13-24 in the overall survey sample (3%). Twenty-seven percent were 25-34 compared to 16% in the total sample.

Table 4.105 Age

Transgender

In-Care Out-of-Care Total

Transgender Total

Sample

Age Cohort # % # % # % %

Age 13-24 1 10.0% 1 20.0% 2 13.3% 3.2%

Age 25-34 3 30.0% 1 20.0% 4 26.7% 16.2%

Age 35-44 0 0.0% 1 20.0% 1 6.7% 19.9%

Age 45-54 4 40.0% 1 20.0% 5 33.3% 30.4%

Age 55+ 2 20.0% 1 20.0% 3 20.0% 28.1%

Age Not Reported 0 0.0% 0 0.0% 0 0.0% 2.2%

Total 10 100.0% 5 100.0% 15 100.0% 100.0%

In-Care n = 10; Out-of-Care n = 5; Combined In-Care/Out-of-Care n = 15

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One respondent reported diagnosis of an intersex condition.

Table 4.106 Intersex Condition

Transgender

Has a medical provider ever diagnosed you with an intersex condition?

In-Care Out-of-Care Total

# % # % # %

Yes 1 10.0% 0 0.0% 1 6.7%

No 9 90.0% 5 100.0% 14 93.3%

Total 10 100.0% 5 100.0% 15 100.0%

In-Care n = 10; Out-of-Care n = 5; Combined In-Care/Out-of-Care n = 15

Transgender survey respondents were almost all from Dallas County, but Denton County was also represented.

Table 4.107 County of Residence

Transgender

In-Care Out-of-Care Total

Transgender Total

Sample

County # % # % # % %

Collin 0 0.0% 0 0.0% 0 0.0% 3.4%

Cooke 0 0.0% 0 0.0% 0 0.0% 0.4%

Dallas 7 70.0% 4 80.0% 11 73.3% 83.1%

Denton 3 30.0% 1 20.0% 4 26.7% 9.5%

Ellis 0 0.0% 0 0.0% 0 0.0% 0.1%

Fannin 0 0.0% 0 0.0% 0 0.0% 0.1%

Grayson 0 0.0% 0 0.0% 0 0.0% 3.2%

Henderson 0 0.0% 0 0.0% 0 0.0% 0.0%

Hunt 0 0.0% 0 0.0% 0 0.0% 0.1%

Kaufman 0 0.0% 0 0.0% 0 0.0% 0.0%

Navarro 0 0.0% 0 0.0% 0 0.0% 0.0%

Rockwall 0 0.0% 0 0.0% 0 0.0% 0.0%

Total 10 100.0% 5 100.0% 15 100.0% 100.0%

In-Care n = 10; Out-of-Care n = 5; Combined In-Care/Out-of-Care n = 15

Transmission Mode Considering transmission mode as identified on the consumer survey, 67% of Transgender reported having sex with a man, 13% reported having sex with a transman, transwoman, transperson or gender nonconforming person transmission, and 13% reported IDU. Comparisons with the total sample are not consistent and therefore not shown.

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Table 4.108 Transmission Mode

Transgender

In-Care Out-of-Care Total

Transgender

Transmission Mode # % # % # %

Having sex with a man 7 70.0% 3 60.0% 10 66.7%

Having sex with a woman 0 0.0% 0 0.0% 0 0.0%

Sharing needles 1 10.0% 1 20.0% 2 13.3%

Blood products/Transfusion 0 0.0% 0 0.0% 0 0.0%

Perinatal transmission (born with it or infected at birth) 0 0.0% 0 0.0% 0 0.0%

Having sex with a transman, transwoman, transperson or gender nonconforming person 1 10.0% 1 20.0% 2 13.3%

Other 0 0.0% 0 0.0% 0 0.0%

Do Not Know 1 10.0% 0 0.0% 1 6.7%

Total 10 100.0% 5 100.0% 15 100.0%

In-Care n = 10; Out-of-Care n = 5; Combined In-Care/Out-of-Care n = 15

Educational Attainment and Employment Transgender respondents reported educational attainment in-line with the overall survey.

 The majority of Transgender respondents reported having some college (27%) or a college degree (27%).

 One-third (33%) graduated high school compared to 35% for the overall survey.

 13% of Transgender respondents did not complete high school compared to 16% overall in the survey.

Compared to the total sample, few differences were noted, except for completed college (27% vs 10%).

Table 4.109 Educational Attainment

Transgender

In-Care Out-of-Care Total

Transgender Total

Sample

Educational Attainment # % # % # % %

Eighth Grade or Less 0 0.0% 0 0.0% 0 0.0% 3.3%

Some High School 2 20.0% 0 0.0% 2 13.3% 12.9%

High School Graduate/GED 3 30.0% 2 40.0% 5 33.3% 34.9%

Technical or Trade School 0 0.0% 0 0.0% 0 0.0% 4.9%

Some College 4 40.0% 0 0.0% 4 26.7% 28.8%

Completed College 1 10.0% 3 60.0% 4 26.7% 10.3%

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In-Care Out-of-Care Total

Transgender Total

Sample

Educational Attainment # % # % # % %

Graduate Education 0 0.0% 0 0.0% 0 0.0% 4.0%

Other 0 0.0% 0 0.0% 0 0.0% 0.9%

Total 10 100.0% 5 100.0% 15 100.0% 100.0%

In-Care n = 10; Out-of-Care n = 5; Combined In-Care/Out-of-Care n = 15

Transgender employment status was similar that of the total sample.

 73% of Transgender respondents were unemployed compared to 76% of the total sample.

Table 4.110 Employment Status

Transgender

In-Care Out-of-Care Total

Transgender Total

Sample

Employment Status # % # % # % %

Work Full-Time 1 10.0% 2 40.0% 3 20.0% 13.3%

Work Part-Time 1 10.0% 0 0.0% 1 6.7% 11.0%

Not Working 8 80.0% 3 60.0% 11 73.3% 75.6%

Total 10 100.0% 5 100.0% 15 100.0% 100.0%

In-Care n = 10; Out-of-Care n = 5; Combined In-Care/Out-of-Care n = 15

Of the 11 Transgender who were not working,

 46% were on disability, similar to 45% of the total sample.

 9% indicated their health precluded them from working even though they were not on disability.

 27% were looking for jobs; 33% of whom were out-of-care compared to 25% of those in-care.

Table 4.111 Employment Status

Transgender

If You Are Not Working, Which Best Describes You?

In-Care Out-of-Care Total

Transgender Total

Sample

# % # % # % %

I am a student 0 0.0% 0 0.0% 0 0.0% 3.4%

I am looking for a job 2 25.0% 1 33.3% 3 27.3% 23.0%

I am retired 0 0.0% 0 0.0% 0 0.0% 4.7%

I work as a volunteer 0 0.0% 0 0.0% 0 0.0% 3.2%

My health keeps me from working - I am not on disability 1 12.5% 0 0.0% 1 9.1%

14.8%

My health keeps me from working - I am on disability 3 37.5% 2 66.7% 5 45.5%

44.8%

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If You Are Not Working, Which Best Describes You?

In-Care Out-of-Care Total

Transgender Total

Sample

# % # % # % %

Other 2 25.0% 0 0.0% 2 18.2% 6.1%

Total 8 100.0% 3 100.0% 11 100.0% 100.0%

In-Care n = 8; Out-of-Care n = 3; Combined In-Care/Out-of-Care n = 11

Income Incomes for Transgender respondents were lower than the total sample. Seventy-three percent of Transgender individuals earned less than $950 a month compared to the total sample (68%), and no respondents earned income greater than $1,901 while 9% of the total sample reported earnings above this amount.

Table 4.112 Income

Transgender

In-Care Out-of-Care Total

Transgender Total

Sample

Monthly Income # % # % # % %

Less than $950 8 80.0% 3 60.0% 11 73.3% 68.1%

$950 - $1,900 2 20.0% 2 40.0% 4 26.7% 22.5%

$1,901 - $2,800 0 0.0% 0 0.0% 0 0.0% 6.7%

More than $2,800 0 0.0% 0 0.0% 0 0.0% 2.6%

Total 10 100.0% 5 100.0% 15 100.0% 100.0%

In-Care n = 10; Out-of-Care n = 5; Combined In-Care/Out-of-Care n = 15

Housing Situation Approximately half (47%) of transgender respondents resided in a home they own in or rent. Four, or 27%, lived at their parent’s or a relative’s home. Two lived in a rooming or boarding house, one in an assisted living facility, and one respondent reported living in a homeless shelter.

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Table 4.113 Housing Situation

Transgender

In-Care Out-of-Care Total

Transgender Total

Sample

Where do you live now? (check only one) # % # % # % %

In an apartment/house/mobile home that I own or rent in my name

5 50.0% 2 40.0% 7 46.7% 52.2%

At my parent's or a relative's home-permanent 3 30.0% 1 20.0% 4 26.7% 8.3%

In a "supportive living" facility (Assisted Living Facility)

1 10.0% 0 0.0% 1 6.7% 7.3%

At another person's apartment/home-permanent 0 0.0% 0 0.0% 0 0.0% 5.9%

At another person's apartment/home-temporary 0 0.0% 0 0.0% 0 0.0% 5.6%

At my parent's or a relative's home-temporary 0 0.0% 0 0.0% 0 0.0% 4.6%

Homeless (on the street or in car) 0 0.0% 0 0.0% 0 0.0% 4.0%

In a half-way house, transitional housing or treatment facility (drug or psychiatric)

0 0.0% 0 0.0% 0 0.0% 4.0%

Homeless Shelter 0 0.0% 1 20.0% 1 6.7% 3.6%

In a rooming or boarding house 1 10.0% 1 20.0% 2 13.3% 2.0%

Residential hospice facility or skilled nursing home 0 0.0% 0 0.0% 0 0.0% 0.1%

Domestic Violence Shelter 0 0.0% 0 0.0% 0 0.0% 0.0%

Other 0 0.0% 0 0.0% 0 0.0% 2.3%

Total 10 100.0% 5 100.0% 15 100.0% 100.0%

In-Care n = 10; Out-of-Care n = 5; Combined In-Care/Out-of-Care n = 15

Substance Use and Mental Health Disorders Consumers asked about drug use in the last six months responded as follows:

 27% of Transgender responded “Yes” to the use of alcohol or drugs.

Table 4.114 Substance Use in the Last 6 Months

Transgender

In-Care Out-of-Care Total

Transgender Total

Sample

Substance Use # % # % # % %

Have Used Drugs or Alcohol in Past 6 Months 3 30.0% 1 20.0% 4 26.7% 56.2%

No Drugs Listed Used 7 70.0% 4 80.0% 11 73.3% 43.8%

Total 10 100.0% 5 100.0% 15 100.0% 100.0%

In-Care n = 10; Out-of-Care n = 5; Combined In-Care/Out-of-Care n = 15

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The consumer survey asked about IV drug use with the following results:

 No respondents admitted to injecting drugs.

 80% refused to respond to the question.

Table 4.115 IV Drug Use Transgender

In-Care Out-of-Care Total

Transgender Total

Sample

IV Drug Use # % # % # % %

Yes 0 0.0% 0 0.0% 0 0.0% 3.3%

No 2 20.0% 1 20.0% 3 20.0% 36.3%

No Response 8 80.0% 4 80.0% 12 80.0% 60.4%

Total 10 100.0% 5 100.0% 15 100.0% 100.0%

In-Care n = 10; Out-of-Care n = 5; Combined In-Care/Out-of-Care n = 15

The most frequent substance used in the last six months by Transgender respondents was marijuana (75%) followed by alcohol (50%) and depressants (50%). The latter was significantly higher than found in the total sample.

Table 4.116 Substance Use in the Last 6 Months

Transgender

In-Care Out-of-Care Total

Transgender Total

Sample

Substance Use # % # % # %

Alcohol 1 33.3% 1 100.0% 2 50.0% 69.1%

Marijuana 2 66.7% 1 100.0% 3 75.0% 46.4%

Depressants 1 33.3% 1 100.0% 2 50.0% 10.2%

Ketamine/PCP 0 0.0% 0 0.0% 0 0.0% 0.3%

Hallucinogens 0 0.0% 0 0.0% 0 0.0% 1.0%

Opioids and Morphine 0 0.0% 0 0.0% 0 0.0% 11.2%

Stimulants 1 33.3% 0 0.0% 1 25.0% 19.9%

Steroids not prescribed by your doctor 0 0.0% 0 0.0% 0 0.0% 0.8%

Prescription painkillers not prescribed by your doctor 0 0.0% 0 0.0% 0 0.0% 6.1%

Inhalants 0 0.0% 0 0.0% 0 0.0% 2.6%

In-Care n = 3; Out-of-Care n = 1; Combined In-Care/Out-of-Care n = 4. Respondents were permitted to choose more than one.

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Respondents who indicated they used alcohol were asked if they used alcohol more than three times a week, and both responded affirmatively. No respondents indicated they were considering substance abuse treatment.

Table 4.117 Alcohol Use Transgender

In-Care Out-of-Care Total

Transgender Total

Sample

Do you Drink Alcohol More Than 3 Times A Week? # % # % # %

%

Yes 1 100.0% 1 100.0% 2 100.0% 29.2%

No 0 0.0% 0 0.0% 0 0.0% 70.8%

Total 1 100.0% 1 100.0% 2 100.0% 100.0%

In-Care n = 1; Out-of-Care n = 1; Combined In-Care/Out-of-Care n = 2

Twenty-seven percent of Transgender survey respondents have received medical treatment for depression in the past 12 months.

Table 4.118 Depression Diagnosis

Transgender

Have You Received Medical Treatment for Depression in the Last 12 Months

In-Care Out-of-Care Total

Transgender Total

Sample

# % # % # % %

Yes 2 20.0% 2 40.0% 4 26.7% 29.7%

No 8 80.0% 3 60.0% 11 73.3% 70.3%

Total 10 100.0% 5 100.0% 15 100.0% 100.0%

In-Care n = 10; Out-of-Care n = 5; Combined In-Care/Out-of-Care n = 15

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DIAGNOSIS AND REFERRAL FOR CARE Nearly half (47%) of Transgender respondents were diagnosed before 2005. Four, or 27%, were diagnosed within the last three years.

Table 4.119 Year of Diagnosis

Transgender

In-Care Out-of-Care Total

Transgender Total

Sample

Year Diagnosed with HIV # % # % # % %

Before 1990 0 0.0% 0 0.0% 0 0.0% 11.8%

1990-1995 2 20.0% 1 20.0% 3 20.0% 12.9%

1996-1999 1 10.0% 1 20.0% 2 13.3% 11.3%

2000-2004 2 20.0% 0 0.0% 2 13.3% 16.5%

2005-2007 1 10.0% 1 20.0% 2 13.3% 9.0%

2008-2010 1 10.0% 0 0.0% 1 6.7% 11.8%

2011-2013 1 10.0% 0 0.0% 1 6.7% 11.6%

2014-2017 2 20.0% 2 40.0% 4 26.7% 14.1%

No Response or Unclear Response 0 0.0% 0 0.0% 0 0.0% 1.0%

Total 10 100.0% 5 100.0% 15 100.0% 100.0%

In-Care n = 10; Out-of-Care n = 5; Combined In-Care/Out-of-Care n = 15

Nearly three-quarters (73%) of Transgender respondents received HIV medical care within three months after diagnosis, a larger percentage than the total sample (50%).

 Two-thirds received care within three months following diagnosis.

 13% received care more than 6 months after their diagnosis.

 13% never received medical care.

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Table 4.120

Care After Diagnosis Transgender

How Soon After Your Diagnosis Did You Go to See a Doctor About Your HIV?

In-Care Out-of-Care Total

Transgender Total

Sample

# % # % # % %

In less than 1 month 1 10.0% 0 0.0% 1 6.7% 24.1%

In less than 3 months 8 80.0% 2 40.0% 10 66.7% 26.5%

Within 3 to 6 months 0 0.0% 0 0.0% 0 0.0% 16.6%

After more than 6 months 1 10.0% 1 20.0% 2 13.3% 28.8%

I have not received HIV medical care 0 0.0% 2 40.0% 2 13.3% 3.7%

No Response 0 0.0% 0 0.0% 0 0.0% 0.1%

Total 10 100.0% 5 100.0% 15 100.0% 100.0%

In-Care n = 10; Out-of-Care n = 5; Combined In-Care/Out-of-Care n = 15

In-Care Problems with HIV Medical Care Fifty-three percent of Transgender respondents reported that it was not hard to get medical care compared to 57% of the total survey respondents. Primary barriers noted by Transgender individuals were:

 “Amount of time it takes at the clinic.”

 “The staff does not understand my culture.”

 “Paperwork needed.”

 “The time it takes to get an appointment.”

Table 4.121 HIV Medical Care Potential Problems

Transgender

In the past year, why was it hard for you to get HIV medical care? (Check all that apply)

Total Transgender

# %

It was not hard to get medical care 8 53.3%

Amount of time it takes at the clinic 3 20.0%

Paperwork needed 3 20.0%

The time it takes to get an appointment 3 20.0%

The staff does not understand my culture 3 20.0%

I cannot afford the co-pays, deductibles, and other costs of treatments and medicines 2 13.3%

I have to miss work to go to medical appointments 2 13.3%

I am afraid of being seen at the clinic 2 13.3%

Other 2 13.3%

No weekend hours 1 6.7%

No evening hours (after 5 pm) 1 6.7%

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In the past year, why was it hard for you to get HIV medical care? (Check all that apply)

Total Transgender

# %

Sometimes I do not feel well enough to go to my appointment 1 6.7%

I do not feel mentally able to deal with the treatment 1 6.7%

It is too hard to follow the medical advice 1 6.7%

I do not have transportation so it's hard to get there 0 0.0%

The clinic only treats HIV and no other medical conditions 0 0.0%

I am in a domestic violence/sexual assault situation 0 0.0%

The staff does not speak my language 0 0.0%

In-Care n = 10; Out-of-Care n = 5; Combined In-Care/Out-of-Care n = 15

Reason for Not Getting Care Fifty-seven consumers who were out-of-care for the last 12 months were asked to provide their reasons for not getting care. Respondents were given a list of reasons and an opportunity to provide additional reasons for being out-of-care. Responses included:

 60% stated they didn’t feel sick.

 40% said, “I am afraid of being seen at the clinic”, and “I do not have money to pay.”

Table 4.122 Not Getting HIV Medical Care

Transgender Out-of-Care

Out-of-Care Transgender

Out-of-Care Total Sample

Why are you not getting HIV medical care? (Check all that apply) # % %

I do not feel sick 3 60.0% 59.6%

I do not need or want medical care 0 0.0% 10.5%

I do not want to think about being HIV positive 1 20.0% 29.8%

I am afraid to get medical care 1 20.0% 10.5%

It is too much trouble 1 20.0% 17.5%

I do not want to take medicines 0 0.0% 28.1%

Too much paperwork is needed 1 20.0% 8.8%

I am afraid to be seen at the clinic 2 40.0% 17.5%

The appointments cause problems with my job 0 0.0% 3.5%

The clinic asks too many personal questions 1 20.0% 12.3%

I do not like the physical exam 0 0.0% 0.0%

I use drugs or alcohol 0 0.0% 15.8%

It is hard to get there (transportation) 0 0.0% 17.5%

Long waiting time to get an appointment 1 20.0% 8.8%

I do not have needed identification (ID)/my ID does not match who I am 0 0.0% 3.5%

Services are not in my language 0 0.0% 0.0%

I do not have legal status in the U.S. 0 0.0% 0.0%

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Out-of-Care Transgender

Out-of-Care Total Sample

Why are you not getting HIV medical care? (Check all that apply) # % %

I do not have money to pay 2 40.0% 22.8%

Other 0 0.0% 12.3%

Out-of-Care n = 5(Answered No to Q4, Q5 AND Q6)

Reason for Dropping Out-of-Care Out-of-care Transgender respondents indicated the following reasons for why it was hard to get HIV medical care:

 “I do not feel sick.”

 “I was tired of taking medicines.”

 “I did not have money.”

 “I was tired of going to the clinic.”

 “The staff does not understand my culture.”

Table 4.123 Why Was It Hard For You to Get HIV Medical Care?

Transgender Out-of-Care

In the past year, why was it hard for you to get HIV medical care? (Check all that apply)

Out-of-Care Transgender

Total Out-of-

Care Sample

# % %

It was hard to keep appointments 1 33.3% 32.3%

I was using drugs 0 0.0% 28.1%

I did not feel sick 2 66.7% 26.9%

I was tired of taking medicines 2 66.7% 26.3%

I did not have money 2 66.7% 24.6%

I needed a break 1 33.3% 19.8%

I was tired of going to the clinic 2 66.7% 18.6%

Other 1 33.3% 18.0%

It was hard to get to the clinic (transportation) 0 0.0% 16.8%

I was using alcohol 0 0.0% 13.8%

The appointments took too long 1 33.3% 12.6%

I did not need or want medical care 0 0.0% 11.4%

I moved and did not know where to go 1 33.3% 11.4%

The staff does not understand my culture 2 66.7% 5.4%

Staff does not understand my language 1 33.3% 1.8%

Out-of-Care n = 3. Respondents were permitted to choose more than one.

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SERVICE NEEDS Top service needs for Transgender individuals include:

 HIV Outpatient Medical Care

 Food Bank

 Dental Visits

 Help Paying for prescription medicine

 Medical Care from a Specialist referred by your HIV medical provider

 Primary Medical Care for general medical care not related to HIV

 Emergency Financial Assistance for Rent/Mortgage or Utilities

 Emergency Long Term Rental Assistance

 Transportation to other services

 Employment services

Table 4.124 Top Service Needs

Transgender

From the list below, check the 5 services you need the most:

In-Care Out-of-Care Total

Transgender Total

Sample

# % # % # % %

HIV Outpatient Medical Care 6 60.0% 2 40.0% 8 53.3% 46.9%

Food Bank 5 50.0% 2 40.0% 7 46.7% 47.9%

Dental Visits 3 30.0% 2 40.0% 5 33.3% 57.8%

Help paying for prescription medicines 4 40.0% 1 20.0% 5 33.3% 32.1%

Medical Care from a Specialist referred by your HIV medical provider

3 30.0% 1 20.0% 4 26.7% 25.3%

Primary Medical Care for general medical care not related to HIV

4 40.0% 0 0.0% 4 26.7% 25.1%

Emergency Financial Assistance for Rent/Mortgage or Utilities

2 20.0% 2 40.0% 4 26.7% 21.1%

Emergency Long-Term Rental Assistance (Voucher)

1 10.0% 2 40.0% 3 20.0% 20.5%

Employment Services 0 0.0% 3 60.0% 3 20.0% 14.5%

Transportation to Other Services 3 30.0% 0 0.0% 3 20.0% 11.0%

Transportation to Medical Care—Bus Pass/Van Service

1 10.0% 1 20.0% 2 13.3% 24.5%

Help paying for co-pays and deductibles for HIV medical care visits and medications

0 0.0% 2 40.0% 2 13.3% 19.8%

Medical Case Management 2 20.0% 0 0.0% 2 13.3% 19.1%

Non-Medical Case Management 1 10.0% 1 20.0% 2 13.3% 12.2%

Nutritional Counseling 1 10.0% 1 20.0% 2 13.3% 12.2%

Education Services 0 0.0% 2 40.0% 2 13.3% 9.5%

Job Training Services 0 0.0% 2 40.0% 2 13.3% 9.2%

Mental Health Counseling 1 10.0% 0 0.0% 1 6.7% 18.9%

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From the list below, check the 5 services you need the most:

In-Care Out-of-Care Total

Transgender Total

Sample

# % # % # % %

If you have health insurance, help with continuing this insurance

0 0.0% 1 20.0% 1 6.7% 7.9%

Facility Based Housing (Assisted Living Facility)

1 10.0% 0 0.0% 1 6.7% 6.7%

Early Intervention to help you get into HIV medical care

0 0.0% 1 20.0% 1 6.7% 2.2%

Legal Services to help you work through a problem obtaining services/benefits, outline advance directives or establish guardianships

0 0.0% 0 0.0% 0 0.0% 9.3%

Outpatient Substance Abuse Treatment 0 0.0% 0 0.0% 0 0.0% 4.2%

Child Care while at a medical or other 0 0.0% 0 0.0% 0 0.0% 2.4%

Respite Care for Adults (Activities during day)

0 0.0% 0 0.0% 0 0.0% 2.2%

Translation or Interpretation 0 0.0% 0 0.0% 0 0.0% 1.4%

Respite Care for HIV positive children 0 0.0% 0 0.0% 0 0.0% 0.4%

In-Care n = 10; Out-of-Care n = 5; Combined In-Care/Out-of-Care n = 15. Respondents were permitted to choose more than one.

KEY INFORMANT INTERVIEWS It should be noted that the comments presented below represent the beliefs, opinions and experiences of those interviewed. Availability

 They need a provider who will see them for their HIV and their transition.

 Service for Transgender persons is sorely lacking. Only two doctors in the Dallas area treat Transgender persons.

Co-Morbidity and Cultural Bias

 They tend to have co-morbidities with HIV, most have mental illness so we need to make sure their mental health needs are addressed.

 There are cultural biases that are not recognized by providers, so we need more education about Transgender needs and special issues regarding job and acceptance.

 Transgender women (especially of color) need workforce support. Many think the only way to build financial sustainability is to do commercial sex work.

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RECOMMENDATIONS 1. Increase support for physicians who treat Transgender patients, with priority to those with HIV or

infectious disease experience. Work with the AETC to provide physician education on the care of HIV+ Transgender individuals.

2. Support provider collaboration with Transgender advocates to educate medical, dental, mental

health, and substance abuse providers about the service needs of the Transgender community. 3. Work with HRSA, AETC and/or Transgender advocates to develop a program on cultural sensitivity

for Dallas area service providers. 4. Encourage providers to develop innovative ways to reach, counsel, test, and link Transgender

consumers to available services.

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YOUTH (AGE 13-24) The consumer survey sample consisted of 22 respondents age 13-24 living with HIV/AIDS, comprising 3% of the survey sample. The youth ages 13-24 sample included seven (32%) in-care and 15 (68%) out-of- care consumers. RESPONDENT OVERVIEW Demographics The gender of youth respondents was slightly more female than the overall survey sample.

 68% of youths ages 13–24 were male compared to 75% in the total sample.

 23% were female, equivalent of the total sample.

 Two transgender respondents were between the ages of 13-24.

Table 4.125 Gender

Youth Ages 13-24

In-Care Out-of-Care Total Youth

Total Sample

Gender Identity # % # % # % %

Male 3 42.9% 12 80.0% 15 68.2% 75.0%

Female 3 42.9% 2 13.3% 5 22.7% 22.8%

Transgender / Other Gender Identity 1 14.3% 1 6.7% 2 9.1% 2.2%

Total 7 100.0% 15 100.0% 22 100.0% 100.0%

In-Care n = 7; Out-of-Care n = 15; Combined In-Care/Out-of-Care n = 22

The majority of youth respondents identified as Black/African-American (64%), which is higher than that of the total sample. The percentage of Hispanic youth (23%) was also higher than the total sample (16%). White youth (9%) were underrepresented relative to the total sample (25%).

 11 out of 15 youth (73%) and 14 (79%) of Black/African American youth respondents were out- of-care.

 2 Hispanic youth respondents reported out-of-care status, while 3 were in-care.

 There were two white youth respondents, and both reported being out-of-care.

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Table 4.126 Race/Ethnicity

Youth Ages 13-24

In-Care Out-of-Care Total Youth

Total Sample

Race/Ethnicity # % # % # % %

Black/African-American 3 42.9% 11 73.3% 14 63.6% 55.5%

White/Caucasian 0 0.0% 2 13.3% 2 9.1% 24.7%

Hispanic/Latino (of any Race) 3 42.9% 2 13.3% 5 22.7% 16.2%

Multi-Racial 1 14.3% 0 0.0% 1 4.5% 2.0%

Native American 0 0.0% 0 0.0% 0 0.0% 0.4%

Asian 0 0.0% 0 0.0% 0 0.0% 0.4%

Other Race/Ethnicity 0 0.0% 0 0.0% 0 0.0% 0.7%

Total 7 100.0% 15 100.0% 22 100.0% 100.0%

In-Care n = 7; Out-of-Care n = 15; Combined In-Care/Out-of-Care n = 22

County of Residence Sixty percent of youth ages 13-24 resided in Dallas County. Denton, Collin and Grayson Counties were also represented.

Table 4.127 County of Residence

Youth Ages 13-24

In-Care Out-of-Care Total Youth

Total Sample

County # % # % # % %

Collin 1 14.3% 1 6.7% 2 9.1% 3.4%

Cooke 0 0.0% 0 0.0% 0 0.0% 0.4%

Dallas 4 57.1% 9 60.0% 13 59.1% 83.1%

Denton 1 14.3% 5 33.3% 6 27.3% 9.5%

Ellis 0 0.0% 0 0.0% 0 0.0% 0.1%

Fannin 0 0.0% 0 0.0% 0 0.0% 0.1%

Grayson 1 14.3% 0 0.0% 1 4.5% 3.2%

Henderson 0 0.0% 0 0.0% 0 0.0% 0.0%

Hunt 0 0.0% 0 0.0% 0 0.0% 0.1%

Kaufman 0 0.0% 0 0.0% 0 0.0% 0.0%

Navarro 0 0.0% 0 0.0% 0 0.0% 0.0%

Rockwall 0 0.0% 0 0.0% 0 0.0% 0.0%

Total 7 100.0% 15 100.0% 22 100.0% 3.4%

In-Care n = 7; Out-of-Care n = 15; Combined In-Care/Out-of-Care n = 22

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Transmission Mode Considering transmission mode as identified on the consumer survey, 64% of youths reported having sex with a male, 12% report perinatal transmission, and 9% report heterosexual transmission. MSM transmission is clearly the major transmission mode of this population.

Table 4.128

Transmission Mode Youth Ages 13-24

In-Care Out-of-Care Total Youth

Total Sample

Transmission Mode # % # % # % %

MSM 3 42.9% 11 73.3% 14 63.6% 50.1%

IDU 0 0.0% 0 0.0% 0 0.0% 6.0%

MSM + IDU 0 0.0% 1 6.7% 1 4.5% 2.4%

Heterosexual 1 14.3% 1 6.7% 2 9.1% 31.9%

Do Not Know 0 0.0% 1 6.7% 1 4.5% 7.9%

Other 3 42.9% 2 13.3% 5 22.7% 9.6%

In-Care n = 7; Out-of-Care n = 15; Combined In-Care/Out-of-Care n = 22

Table 4.129

Transmission Mode Youth Ages 13-24

In-Care Out-of-Care Total

Transmission Mode # % # % # %

Having sex with a man 5 71.4% 13 68.4% 18 69.2%

Having sex with a woman 0 0.0% 3 15.8% 3 11.5%

Sharing needles 0 0.0% 1 5.3% 1 3.8%

Blood products/Transfusion 0 0.0% 0 0.0% 0 0.0%

Perinatal transmission (born with it or infected at birth) 2 28.6% 1 5.3% 3 11.5%

Having sex with a transman, transwoman, transperson or gender nonconforming person 0 0.0% 0 0.0% 0 0.0%

Other 0 0.0% 0 0.0% 0 0.0%

Do Not Know 0 0.0% 1 5.3% 1 3.8%

Total 7 100.0% 19 100.0% 26 100.0%

In-Care n = 7; Out-of-Care n = 19; Combined In-Care/Out-of-Care n = 26 NOTE: The 22 respondents 13-24 were asked to identify all that apply.

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Educational Attainment and Employment The majority of youth respondents reported either high school graduate/GED status (36%), or some college (41%). Five respondents (23%) had not completed high school.

Table 4.130 Educational Attainment

Youth Ages 13-24

In-Care Out-of-Care Total Youth

Total Sample

Educational Attainment # % # % # % %

Eighth Grade or Less 0 0.0% 0 0.0% 0 0.0% 3.3%

Some High School 1 14.3% 4 26.7% 5 22.7% 12.9%

High School Graduate/GED 3 42.9% 5 33.3% 8 36.4% 34.9%

Technical or Trade School 0 0.0% 0 0.0% 0 0.0% 4.9%

Some College 3 42.9% 6 40.0% 9 40.9% 28.8%

Completed College 0 0.0% 0 0.0% 0 0.0% 10.3%

Graduate Education 0 0.0% 0 0.0% 0 0.0% 4.0%

Other 0 0.0% 0 0.0% 0 0.0% 0.9%

Total 7 100.0% 15 100.0% 22 100.0% 100.0%

In-Care n = 7; Out-of-Care n = 15; Combined In-Care/Out-of-Care n = 22

Sixty-four percent of the youth sample were not working compared to 76% of the total sample. Eighteen percent were working full-time and 18% part-time.

 Of those not working, 43% were looking for a job, and 21% were current students.

 Two respondents, or 14% of those not working were on disability.

Tables 4.131 Employment Status Youth Ages 13-24

In-Care Out-of-Care Total Youth

Total Sample

Employment Status # % # % # % %

Work Full-Time 1 14.3% 3 20.0% 4 18.2% 13.3%

Work Part-Time 1 14.3% 3 20.0% 4 18.2% 11.0%

Not Working 5 71.4% 9 60.0% 14 63.6% 75.6%

Total 7 100.0% 15 100.0% 22 100.0% 100.0%

In-Care n = 7; Out-of-Care n = 15; Combined In-Care/Out-of-Care n = 22

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Table 4.132 Unemployed Status

Youth Ages 13-24

If You Are Not Working, Which Best Describes You?

In-Care Out-of-Care Total Youth

Total Sample

# % # % # % %

I am a student 1 20.0% 2 22.2% 3 21.4% 3.4%

I am looking for a job 1 20.0% 5 55.6% 6 42.9% 23.0%

I am retired 0 0.0% 0 0.0% 0 0.0% 4.7%

I work as a volunteer 0 0.0% 0 0.0% 0 0.0% 3.2%

My health keeps me from working - I am not on disability 0 0.0% 0 0.0% 0 0.0%

14.8%

My health keeps me from working - I am on disability 1 20.0% 1 11.1% 2 14.3%

44.8%

Other 2 40.0% 1 11.1% 3 21.4% 6.1%

Total 5 100.0% 9 100.0% 14 100.0% 100.0%

In-Care n = 5; Out-of-Care n = 9; Combined In-Care/Out-of-Care n = 14

Housing Situation About one-third of youth respondents reported living in a place owned or rented in their name. The other two-thirds reported various living situations.

 Four (18%) reported living in a parent or relative home permanently. Two (9%) reported living in another person’s home permanently.

 Four, or 18% reported living in a parent or relative home temporarily. Two (9%) reported living in another person’s home temporarily.

 Two (9%) reported living in an assisted living facility, and one (5%) in a residential hospice facility or skilled nursing home.

Table 4.133

Housing Youth Ages 13-24

Where do you live now? (check only one) In-Care Out-of-Care Total Youth

Total Sample

# % # % # % %

In an apartment/house/mobile home that I own or rent in my name

3 42.9% 4 26.7% 7 31.8% 52.2%

At my parent's or a relative's home-permanent 2 28.6% 2 13.3% 4 18.2% 8.3%

In a "supportive living" facility (Assisted Living Facility)

0 0.0% 2 13.3% 2 9.1% 7.3%

At another person's apartment/home-permanent 0 0.0% 2 13.3% 2 9.1% 5.9%

At another person's apartment/home-temporary 0 0.0% 4 26.7% 4 18.2% 5.6%

At my parent's or a relative's home-temporary 1 14.3% 1 6.7% 2 9.1% 4.6%

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Where do you live now? (check only one) In-Care Out-of-Care Total Youth

Total Sample

# % # % # % %

Homeless (on the street or in car) 0 0.0% 0 0.0% 0 0.0% 4.0%

In a half-way house, transitional housing or treatment facility (drug or psychiatric)

0 0.0% 0 0.0% 0 0.0% 4.0%

Homeless Shelter 0 0.0% 0 0.0% 0 0.0% 3.6%

In a rooming or boarding house 0 0.0% 0 0.0% 0 0.0% 2.0%

Residential hospice facility or skilled nursing home 1 14.3% 0 0.0% 1 4.5% 0.1%

Domestic Violence Shelter 0 0.0% 0 0.0% 0 0.0% 0.0%

Other 0 0.0% 0 0.0% 0 0.0% 2.3%

Total 7 100.0% 15 100.0% 22 100.0% 100.0%

In-Care n = 7; Out-of-Care n = 15; Combined In-Care/Out-of-Care n = 22

Income Understandably, incomes for youth were lower than the total sample. Seventy-seven percent of youths earned less than $950 a month compared to the total sample (68%).

Table 4.134 Income

Youth Ages 13-24

In-Care Out-of-Care Total Youth

Total Sample

Monthly Income # % # % # % %

Less than $950 5 71.4% 12 80.0% 17 77.3% 68.1%

$950 - $1,900 0 0.0% 2 13.3% 2 9.1% 22.5%

$1,901 - $2,800 2 28.6% 1 6.7% 3 13.6% 6.7%

More than $2,800 0 0.0% 0 0.0% 0 0.0% 2.6%

Total 7 100.0% 15 100.0% 22 100.0% 100.0%

In-Care n = 7; Out-of-Care n = 15; Combined In-Care/Out-of-Care n = 22

Substance Use and Mental Health Disorders The consumer survey asked about current drug and alcohol use with the following results:

 The majority (77%) of youth survey respondents used drugs or alcohol in the past six months.

 One youth respondent admitted to injecting drugs, and that respondent was out-of-care.

 Over 54% refused to respond to the question regarding IV drug use.

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Table 4.135 Substance Abuse Youth Ages 13-24

In-Care Out-of-Care Total Youth

Total Sample

Substance Use # % # % # % %

Have Used Drugs or Alcohol in Past 6 Months 4 57.1% 13 86.7% 17 77.3% 56.2%

No Drugs Listed Used 3 42.9% 2 13.3% 5 22.7% 43.8%

Total 7 100.0% 15 100.0% 22 100.0% 100.0%

In-Care n = 7; Out-of-Care n = 15; Combined In-Care/Out-of-Care n = 22

Table 4.136 IV Drug Use

Youth Ages 13-24

In-Care Out-of-Care Total Youth

Total Sample

IV Drug Use # % # % # % %

Yes 0 0.0% 1 6.7% 1 4.5% 3.3%

No 3 42.9% 6 40.0% 9 40.9% 36.3%

No Response 4 57.1% 8 53.3% 12 54.5% 60.4%

Total 7 100.0% 15 100.0% 22 100.0% 100.0%

In-Care n = 7; Out-of-Care n = 15; Combined In-Care/Out-of-Care n = 22

In contrast to the total sample where alcohol was most frequently cited, the most frequent substance used by youth in the last six months was marijuana (82%), followed by alcohol (71%) and stimulants (24%).

 Marijuana use was reported by 12 out of 14, or 92% of out-of-care respondents.

 Alcohol use was reported by 85% of out-of-car respondents.

 Of the 17 youth respondents using drugs, 13 were out-of-care and 4 were in-care.

Table 4.137 Substance Use in the Last 6 Months

Youth Ages 13-24

In-Care Out-of-Care Total Youth

Total Sample

Substance Use # % # % # % %

Alcohol 1 25.0% 11 84.6% 12 70.6% 69.1%

Marijuana 2 50.0% 12 92.3% 14 82.4% 46.4%

Depressants 2 50.0% 1 7.7% 3 17.6% 10.2%

Ketamine/PCP 0 0.0% 1 7.7% 1 5.9% 0.3%

Hallucinogens 0 0.0% 1 7.7% 1 5.9% 1.0%

Opioids and Morphine 0 0.0% 3 23.1% 3 17.6% 11.2%

Stimulants 1 25.0% 3 23.1% 4 23.5% 19.9%

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In-Care Out-of-Care Total Youth

Total Sample

Substance Use # % # % # % %

Steroids not prescribed by your doctor 0 0.0% 0 0.0% 0 0.0% 0.8%

Prescription painkillers not prescribed by your doctor 0 0.0% 1 7.7% 1 5.9% 6.1%

Inhalants 0 0.0% 0 0.0% 0 0.0% 2.6%

In-Care n = 4; Out-of-Care n = 13; Combined In-Care/Out-of-Care n = 17

Of the 12 youth survey respondents reporting alcohol use, seven reported using alcohol more than three times per week.

 Three (18%) youth respondents reporting substance or alcohol use have thought about seeking substance abuse treatment.

Table 4.138 Alcohol Use

Youth Ages 13-24

Do you Drink Alcohol More Than 3 Times A Week?

In-Care Out-of-Care Total Youth

Total Sample

# % # % # % %

Yes 0 0.0% 7 63.6% 7 58.3% 29.2%

No 1 100.0% 4 36.4% 5 41.7% 70.8%

Total 1 100.0% 11 100.0% 12 100.0% 100.0%

In-Care n = 1; Out-of-Care n = 11; Combined In-Care/Out-of-Care n = 12

Table 4.139

Considering Treatment Youth Ages 13-24

Have Thought About Seeking Substance Abuse Treatment

In-Care Out-of-Care Total Youth

Total Sample

# % # % # % %

Yes 1 25.0% 2 15.4% 3 17.6% 28.4%

No 3 75.0% 11 84.6% 14 82.4% 71.6%

No Response 0 0.0% 0 0.0% 0 0.0% 1.3%

Total 4 100.0% 13 100.0% 17 100.0% 100.0%

In-Care n = 4; Out-of-Care n = 13; Combined In-Care/Out-of-Care n = 17

Nine percent of youth consumer survey respondents were diagnosed with depression, compared to 30% in the total sample. While the small sample size does not allow for conclusion, it is apparent that youth do not receive adequate mental health counseling.

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Table 4.140

Depression Diagnosis Youth Ages 13-24

Have You Received Medical Treatment for Depression in the Last 12 Months

In-Care Out-of-Care Total Youth

Total Sample

# % # % # % %

Yes 1 14.3% 1 6.7% 2 9.1% 29.7%

No 6 85.7% 14 93.3% 20 90.9% 70.3%

Total 7 100.0% 15 100.0% 22 100.0% 100.0%

In-Care n = 7; Out-of-Care n = 15; Combined In-Care/Out-of-Care n = 22

DIAGNOSIS AND REFERRAL FOR CARE The majority of youth consumer survey respondents were diagnosed in the last three years between 2014- 2017.

 More than 86% of youth consumers were diagnosed in 2011 or after.

Table 4.141 Year of Diagnosis Youth Ages 13-24

In-Care Out-of-Care Total Youth

Total Sample

Year Diagnosed with HIV # % # % # % %

Before 1990 0 0.0% 0 0.0% 0 0.0% 11.8%

1990-1995 1 14.3% 1 6.7% 2 9.1% 12.9%

1996-1999 0 0.0% 0 0.0% 0 0.0% 11.3%

2000-2004 1 14.3% 0 0.0% 1 4.5% 16.5%

2005-2007 0 0.0% 0 0.0% 0 0.0% 9.0%

2008-2010 0 0.0% 0 0.0% 0 0.0% 11.8%

2011-2013 1 14.3% 4 26.7% 5 22.7% 11.6%

2014-2017 4 57.1% 10 66.7% 14 63.6% 14.1%

No Response or Unclear Response 0 0.0% 0 0.0% 0 0.0% 1.0%

Total 7 100.0% 15 100.0% 22 100.0% 100.0%

In-Care n = 7; Out-of-Care n = 15; Combined In-Care/Out-of-Care n = 22

Differences exist in how quickly in-care and out-of-care/returned to care youth consumers accessed medical care following diagnosis.

 43% of in-care compared to 13% of out-of-care consumers reported seeing a doctor within three months.

 40% of out-of-care consumers had not received HIV medical care while every in-care youth respondent reported receiving HIV medical care.

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 The proportion of youth respondents who reported not receiving medical care for HIV (27%) was substantially greater than the total sample (4%).

Table 4.142

Care After Diagnosis Youth Ages 13-24

How Soon After Your Diagnosis Did You Go To See a Doctor About Your HIV?

In-Care Out-of-Care Total Youth

Total Sample

# % # % # % %

In less than 1 month 2 28.6% 3 20.0% 5 22.7% 24.1%

In less than 3 months 3 42.9% 2 13.3% 5 22.7% 26.5%

Within 3 to 6 months 1 14.3% 3 20.0% 4 18.2% 16.6%

After more than 6 months 1 14.3% 1 6.7% 2 9.1% 28.8%

I have not received HIV medical care 0 0.0% 6 40.0% 6 27.3% 3.7%

No Response 0 0.0% 0 0.0% 0 0.0% 0.1%

Total 7 100.0% 15 100.0% 22 100.0% 100.0%

In-Care n = 7; Out-of-Care n = 15; Combined In-Care/Out-of-Care n = 22

BARRIERS TO CARE In-Care Seventy-one percent of in-care youth respondents did not find it hard to get care compared to 57% of the total sample of consumers. Affordability of co-pays, deductibles, and other costs of treatments and medicines, paperwork, and transportation were the predominant barriers noted.

Table 4.143 HIV Medical Care Potential Problems

Youth Ages 13-24 In-Care

In the past year, why was it hard for you to get HIV medical care? (Check all that apply)

In-Care Youth

In-Care Total

Sample

# % %

It was not hard to get medical care 5 71.4% 56.5%

I cannot afford the co-pays, deductibles, and other costs of treatments and medicines 2 28.6% 9.0%

Paperwork needed 1 14.3% 12.9%

I do not have transportation so it's hard to get there 1 14.3% 12.0%

The time it takes to get an appointment 1 14.3% 9.4%

No weekend hours 1 14.3% 8.8%

No evening hours (after 5 pm) 1 14.3% 7.2%

Other 1 14.3% 4.8%

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In the past year, why was it hard for you to get HIV medical care? (Check all that apply)

In-Care Youth

In-Care Total

Sample

# % %

Amount of time it takes at the clinic 0 0.0% 15.1%

I have to miss work to go to medical appointments 0 0.0% 7.4%

Sometimes I do not feel well enough to go to my appointment 0 0.0% 5.7%

I am afraid of being seen at the clinic 0 0.0% 3.7%

I do not feel mentally able to deal with the treatment 0 0.0% 1.8%

The clinic only treats HIV and no other medical conditions 0 0.0% 2.6%

It is too hard to follow the medical advice 0 0.0% 0.2%

The staff does not understand my culture 0 0.0% 1.1%

I am in a domestic violence/sexual assault situation 0 0.0% 0.4%

The staff does not speak my language 0 0.0% 0.2%

In-Care n = 7; Out-of-Care n = 15; Combined In-Care/Out-of-Care n = 22

Twenty percent of out-of-care youth respondents did not find it hard to get care compared to 57% of the total sample of consumers. For those who did find it hard the following barriers were noted:

 “I am afraid of being seen at the clinic.”

 “Amount of time it takes at the clinic.”

 “Paperwork needed.”

 “The time it takes to get an appointment.”

Table 4.144 HIV Medical Care Potential Problems

Youth Ages 13-24 Out-of-Care

In the past year, why was it hard for you to get HIV medical care? (Check all that apply)

Out-of-Care Youth

Out-of-Care Total

Sample

# % %

I am afraid of being seen at the clinic 5 33.3% 10.4%

Amount of time it takes at the clinic 4 26.7% 20.4%

It was not hard to get medical care 3 20.0% 35.4%

Paperwork needed 3 20.0% 20.8%

The time it takes to get an appointment 3 20.0% 14.6%

No weekend hours 3 20.0% 10.8%

No evening hours (after 5 pm) 3 20.0% 11.7%

It is too hard to follow the medical advice 3 20.0% 6.3%

Sometimes I do not feel well enough to go to my appointment 2 13.3% 9.2%

I do not feel mentally able to deal with the treatment 2 13.3% 7.9%

The clinic only treats HIV and no other medical conditions 2 13.3% 4.6%

I cannot afford the co-pays, deductibles, and other costs of treatments and medicines

1 6.7% 15.8%

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In the past year, why was it hard for you to get HIV medical care? (Check all that apply)

Out-of-Care Youth

Out-of-Care Total

Sample

# % %

I have to miss work to go to medical appointments 1 6.7% 10.0%

I do not have transportation so it's hard to get there 1 6.7% 15.8%

The staff does not understand my culture 1 6.7% 3.3%

I am in a domestic violence/sexual assault situation 1 6.7% 1.3%

The staff does not speak my language 1 6.7% 0.8%

Other 0 0.0% 7.9%

In-Care n = 7; Out-of-Care n = 15; Combined In-Care/Out-of-Care n = 22

Reason for Not Getting Care Fifty-seven youth respondents who were out-of-care during the last 12 months were asked to provide reasons for not being in care. The most common reasons for not being in care were:

 “I did not feel sick”

 “I do not want to think about being HIV+”

 “I do not need or want medical care”

 “I do not have money to pay,” (tied for third)

Table 4.145 Why Are You Not Getting HIV Medical Care?

Youth Ages 13-24 Out-of-Care

Why are you not getting HIV medical care? (Check all that apply) Out-of-Care

Youth

Out-of-Care Total

Sample

# % %

I do not feel sick 6 10.5% 59.6%

I do not need or want medical care 3 5.3% 10.5%

I do not want to think about being HIV positive 4 7.0% 29.8%

I am afraid to get medical care 0 0.0% 10.5%

It is too much trouble 2 3.5% 17.5%

I do not want to take medicines 2 3.5% 28.1%

Too much paperwork is needed 0 0.0% 8.8%

I am afraid to be seen at the clinic 2 3.5% 17.5%

The appointments cause problems with my job 0 0.0% 3.5%

The clinic asks too many personal questions 1 1.8% 12.3%

I do not like the physical exam 0 0.0% 0.0%

I use drugs or alcohol 2 3.5% 15.8%

It is hard to get there (transportation) 1 1.8% 17.5%

Long waiting time to get an appointment 0 0.0% 8.8%

I do not have needed identification (ID)/my ID does not match who I am 0 0.0% 3.5%

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Why are you not getting HIV medical care? (Check all that apply) Out-of-Care

Youth

Out-of-Care Total

Sample

# % %

Services are not in my language 0 0.0% 0.0%

I do not have legal status in the U.S. 0 0.0% 0.0%

I do not have money to pay 3 5.3% 22.8%

Other 2 3.5% 12.3%

Out-of-Care n = 57 (Answered No to Q4, Q5 AND Q6). Respondents were permitted to choose more than one.

Reasons for Dropping Out-of-Care Youth who had left care for more than six years in the last six months were asked why they dropped out- of-care. The two most frequent reasons given for not receiving medical care were that it was hard to keep appointments and not feeling sick.

 83% did not feel sick, compared to 27% of the total sample.

 38% found it difficult to keep appointments.

Table 4.146 Reasons for Dropping Out-of-Care

Youth Ages 13-24 Out-of-Care

In the past year, why was it hard for you to get HIV medical care? (Check all that apply)

Out-of-Care Youth

Out-of-Care Total Sample

# % %

It was hard to keep appointments 3 50.0% 32.3%

I was using drugs 2 33.3% 28.1%

I did not feel sick 5 83.3% 26.9%

I was tired of taking medicines 1 16.7% 26.3%

I did not have money 2 33.3% 24.6%

I needed a break 1 16.7% 19.8%

I was tired of going to the clinic 2 33.3% 18.6%

Other 0 0.0% 18.0%

It was hard to get to the clinic (transportation) 0 0.0% 16.8%

I was using alcohol 2 33.3% 13.8%

The appointments took too long 1 16.7% 12.6%

I did not need or want medical care 2 33.3% 11.4%

I moved and did not know where to go 1 16.7% 11.4%

The staff does not understand my culture 0 0.0% 5.4%

Staff does not understand my language 0 0.0% 1.8%

Out-of-Care n = 6. Respondents were permitted to choose more than one.

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SERVICE NEEDS Youth survey respondents most frequently identified service needs ranging from dental care visits to medical case management. The top needs include:

 Dental visits

 Transportation to medical care

 Help paying for prescriptions/medications

 Help paying for co-pays, deductibles for HIV medical care visits and medications

 Employment Services

 Education services

 Food bank

 Primary medical care unrelated to HIV

 Medical care from a specialist

 Medical case management

 Nonmedical case management Top needs among the total survey respondents included four categories that Youth did not identify in top 10:

 Food bank.

 HIV outpatient medical care.

 Emergency long-term rental assistance voucher.

 Emergency financial assistance for rent/mortgage or utilities.

Table 4.147 Service Needs

Youth Ages 13-24

From the list below, check the 5 services you need the most:

In-Care Out-of-Care Total Youth

Total Sample

# % # % # % %

Dental Visits 3 42.9% 11 73.3% 14 63.6% 57.8%

Help paying for prescription medicines 2 28.6% 6 40.0% 8 36.4% 32.1%

Transportation to Medical Care—Bus Pass/Van Service

0 0.0% 8 53.3% 8 36.4% 24.5%

Help paying for co-pays and deductibles for HIV medical care visits and medications

1 14.3% 6 40.0% 7 31.8% 19.8%

Employment Services 1 14.3% 6 40.0% 7 31.8% 14.5%

Education Services 2 28.6% 5 33.3% 7 31.8% 9.5%

Food Bank 1 14.3% 5 33.3% 6 27.3% 47.9%

Primary Medical Care for general medical care not related to HIV

1 14.3% 5 33.3% 6 27.3% 25.1%

Medical Care from a Specialist referred by your HIV medical provider

0 0.0% 5 33.3% 5 22.7% 25.3%

Non-Medical Case Management 0 0.0% 5 33.3% 5 22.7% 12.2%

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From the list below, check the 5 services you need the most:

In-Care Out-of-Care Total Youth

Total Sample

# % # % # % %

HIV Outpatient Medical Care 1 14.3% 3 20.0% 4 18.2% 46.9%

Job Training Services 0 0.0% 3 20.0% 3 13.6% 9.2%

Medical Case Management 1 14.3% 1 6.7% 2 9.1%

Mental Health Counseling 0 0.0% 2 13.3% 2 9.1% 18.9%

Transportation to Other Services 1 14.3% 1 6.7% 2 9.1% 11.0%

Emergency Financial Assistance for Rent/Mortgage or Utilities

0 0.0% 1 6.7% 1 4.5% 21.2%

If you have health insurance, help with continuing this insurance

0 0.0% 1 6.7% 1 4.5% 7.9%

Outpatient Substance Abuse Treatment 0 0.0% 1 6.7% 1 4.5% 4.2%

Child Care while at a medical or other appointment

0 0.0% 1 6.7% 1 4.5% 2.4%

Emergency Long-Term Rental Assistance (Voucher)

0 0.0% 0 0.0% 0 0.0% 20.5%

Nutritional Counseling 0 0.0% 0 0.0% 0 0.0% 12.2%

Legal Services to help you work through a problem obtaining services/benefits, outline advance directives or establish guardianships

0 0.0% 0 0.0% 0 0.0% 9.3%

Facility Based Housing (Assisted Living Facility) 0 0.0% 0 0.0% 0 0.0% 6.7%

Respite Care for Adults (Activities during day) 0 0.0% 0 0.0% 0 0.0% 2.2%

Early Intervention to help you get into HIV medical care

0 0.0% 0 0.0% 0 0.0% 2.2%

Translation or Interpretation 0 0.0% 0 0.0% 0 0.0% 1.4%

Respite Care for HIV positive children 0 0.0% 0 0.0% 0 0.0% 0.4%

In-Care n = 7; Out-of-Care n = 15; Combined In-Care/Out-of-Care n = 22

KEY INFORMANT INTERVIEWS The comments presented below represent the beliefs, opinions, and experiences of the key informants interviewed. Key informants were asked about barriers faced by youth who never linked to care. Sex Education

 Dallas County does tend to be progressive in addressing sexual activity among 13-24 year olds but it’s not done in a comprehensive manner where students spend most of their time – in school.

 Comprehensive sex education, in some form, even if it can’t be in the schools.

 Sex education is so important for youth.

 In Texas, it’s a failure of the school system not to allow sex education. Reaching this population and is the biggest challenge and their lack of education is their biggest need.

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Prevention Messaging

 We can’t reach this group without knowing how to make the message effective.

 Education – they need as much HIV prevention as possible. FOCUS GROUPS AND INTERVIEWS The comments presented below represent the beliefs, opinions, and experiences of Provider Focus Group participants with regard to the barriers they believe are faced by youth. Health Coverage Issues

 They don’t know where the resources are and they don’t have access to funds because Texas didn’t expand Medicaid and they don’t know how to use the Ryan White System.

 While it was a blessing that the ACA allowed children to be on their parents’ health plan until they were 26, if they don’t have HIV and they don’t want their parents to know, then they don’t get treatment.

 Kids who are coming off CHIP and Medicaid don’t have experience with private insurance; and there is no counseling for those transitioning from CHIP to adult Medicaid.

The following beliefs, opinions and experiences were expressed by Consumer Focus Group members.

 There are a lot of places we can’t go (e.g., school) in order to get the message out because they don’t want us to.

 Young people don’t think about the risk.

 Someone, a parent, needs to talk about risk to their kids and grandkids. Direct service and Planning Council focus group participants provided additional information regarding barriers they believe young people face, including issues related to transportation, mental health services, denial, and parental disclosure.

 The real problem with the age group 20-26 is that they are incredibly difficult to keep engaged in care. They seem to be at some level of denial or they don’t think they’re sick or are going to get sicker, so it’s not a priority for them to be in treatment or take their medications; and we really struggle to keep them in care.

 I think transportation is a big issue; physically getting around.

 Another top issue is stigma; they don’t want to be seen at these clinics or agencies that provide these services because they don’t want people to think they are HIV+.

 Younger people think they know everything and they feel good, they think they don’t look sick and very rarely do they go to the doctor unless they feel sick.

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RECOMMENDATIONS 1. HIV+ youth are difficult to find and even more difficult to link to care. Efforts to engage in common

communication methods, i.e. social media, should be emphasized as an important avenue to pursue.

2. Youth represent the newest priority population in the Dallas Planning Area. Education and

appropriate messaging to this group appear particularly challenging to overcome and should be given strong consideration with regard to follow-up activities.

3. The County Health Department should meet with the local school districts to discuss rates of teen

pregnancies, STDs, alcohol and other substance use and HIV among youth as a continuing public health issue, in an effort to broaden the school curriculum for health education to include information and tactics on prevention and healthy behaviors. Priority should be placed on schools where high risk behaviors are known to exist.

4. Encourage Ryan White providers to increase their use of popular social media sites, apps (used by

teens and young adults) to provide outreach and early intervention services. 5. Enhance prevention and outreach activities by having providers hold events on college campuses

and at events where young people are likely to gather. Utilize peer outreach whenever possible.

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5. SERVICE CATEGORIES This service category analysis integrates results of each component of the needs assessment – the consumer survey, provider Focus Group discussions, profile of provider capacity, resource inventory, and epidemiological data. SERVICES IN THIS REPORT The Health Resources and Services Administration (HRSA) has designated services as either “core” or “support.” At least 75% of RWHAP funds must be allocated to core services, and no more than 25% on support services unless they receive an approved waiver to this requirement. The core, support and other services evaluated by the consumer survey are presented below. The HRSA service title is followed by the description of that service used in the consumer survey. Core Services (Outpatient) Ambulatory Medical Care (OAMC)

 HIV Outpatient Medical Care

 (For women) Outpatient OB/GYN Care Visits

 Primary Medical Care for general medical care not related to HIV

 Medical Care from a Specialist referred by your HIV doctor (i.e., heart, skin, diabetes, other specialist)

 Child assessment and early intervention AIDS Drug Assistance Program (ADAP) and AIDS Pharmaceutical Assistance (local)

 Help paying for prescription medications

 Help paying for medications and prescriptions/other pharmaceutical assistance Early Intervention Services (EIS)

 Early intervention to help you get into HIV medical care Health Insurance Premium and Cost Sharing Assistance for Low Income Individuals

 Help with your health premiums, co-pays or deductibles Home Health Care

 Home health care Home and Community-Based Services

 Home and community-based health services – home aides and assistants Hospice Services

 Hospice Services

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Medical Case Management, including Treatment Adherence Services

 Help with coordination of your medical care offered at medical and dental care locations

 Treatment adherence counseling Medical Nutrition Therapy

 Medical nutrition counseling Mental Health Services

 Mental health counseling Oral Health Care

 Dental visits Substance Abuse Outpatient Care

 Outpatient substance abuse treatment Support Services Child Care Services

 Child care while at medical or other appointment Emergency Financial Assistance

 Financial assistance for utilities Food Bank/Home Delivered Meals

 Food Bank Health Education/Risk Reduction

 Education on how to prevent HIV

 Treatment adherence counseling Housing

 Emergency assistance for rent or mortgage

 Facility-Based Housing (Assisted Living Facility)

 Long-Term Housing Legal Services

 See Other Professional Services Linguistics Services

 Translation or interpretation Medical Transportation

 Transportation to medical care

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Non-Medical Case Management

 Non-Medical Case Management (help accessing medical and other needed services) Other Professional Services (including Permanency Planning)

 Legal services to help you work through a problem obtaining service benefits, outline advance directives, or establish guardianships

 Permanency planning – legal help with writing your will Outreach Services

 Outreach to help you get HIV tested and into HIV medical care Psychosocial Support Services

 Group or individual counseling to help cope with HIV Referral for Health Care Support Services

 Referral for help getting health care or supportive services Rehabilitation Services

 Rehabilitation services Respite Care

 Respite care for adults

 Respite care for children Substance Abuse Services (Residential)

 Substance abuse services (residential) SERVICE NEED AND BARRIERS The consumer survey services section asked the following questions about the 35 core and support

services outlined:

 Do You Use This Service Now or Over the Past Year?  If a service is being used, it is assumed the service is needed.  If the service is being used, the next question asks about ease of use.  If the service is not being used, the next question asks about need for the service.

 How Easy Was It For You To Get the Service?  The number and percentage of people who use the service and found it easy to get is

presented as Need Met Easily  The number and percentage of people who use the service and found it hard or

somewhat hard to get is presented as Need Met Hard.  Anyone with a service that was hard or somewhat hard to get was asked the reason

under the barriers section.

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 Unfulfilled need for a service.  If someone is not using the service but states a need for it, he/she is considered to have

an unfulfilled need for the service.  The number and percentage of people who have an unfulfilled need is presented as

Need Not Met.  Anyone with an unfulfilled need was asked the reason under the barriers section.

 Barriers to Care.  If a service fulfilled the criteria for either Need Met Hard or Somewhat Hard or Need

Not Met, the respondent was asked either, “What is the main reason you were not able to get this service?” or “What is the main reason this service was hard to get?”

 Specific barriers were identified for each service.  A list of “problems” with HIV medical care asked early in the survey replaced the barrier

questions for Ambulatory/Outpatient Medical Care. The service need and barriers are provided for the total sample, in-care and out-of-care consumer respondents. For most services, the Priority Populations’ service need and barriers are also presented. The total number of respondents for any question is displayed with “n.” GAP ANALYSIS The gap analysis utilizes the results of the consumer survey along with the provider Focus Groups, out- of-care consumer interviews, Key Informant Interviews, provider survey and the provider inventory to inform the analysis. In doing so, the following issues are considered:

 How highly the service was ranked as needed by survey respondents.

 The unfulfilled need ranking of respondents.

 The current availability and capacity as reported by the provider survey and inventory.

 The degree of difficulty consumers report, when attempting to access the service.

 The percent of respondents experiencing barriers, and qualitative information obtained through interviews and provider Focus Groups.

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Table 5.1 Service Need Ranking

Total Sample: In-Care and Out-of-Care

Total Sample In-Care Out-Of-Care

SERVICE Total Need Rank

% Of Need

Reported In The

Sample

Unfulfilled Need

Total Need Rank

Unfulfilled Need Rank

Total Need

Unfulfilled Need

Dental Visits 1 67.45% 1 2 1 1 1

HIV Outpatient Medical Care 2 67.37% 18 1 20 2 12

Food Bank 3 65.26% 8 3 9 4 8

Help Paying for Prescription Medications 4 63.93% 13 4 13 3 6

Medical Case Management—help with coordination of your medical care offered at medical and dental care locations.

5 63.28% 15 5 17 *5 8

Help Paying for Prescription Medications/Other Pharmaceutical Assistance

6 61.68% 11 7 12 *5 7

Medical Care from a Specialist referred by your HIV doctor (i.e., heart, skin, diabetes, other specialist)

7 60.06% 12 6 11 10 16

Transportation to Medical Care—Bus Pass/Van Service 8 58.23% 17 8 16 7 16

Help paying for co-pays and deductibles for HIV medical care visits and medications

9 57.49% 5 9 6 9 4

Long-Term Housing 10 57.49% 2 10 2 8 2

Non-Medical Case Management—help accessing support services 11 56.29% 18 11 19 11 13

Referral help for getting health care or supportive services 12 53.19% 14 12 13 12 8

Mental Health Counseling 13 52.00% 16 13 13 13 14

Health Education and Risk Reduction information on how to prevent HIV 14 49.71% 20 16 23 14 20

Emergency Assistance for Rent, Mortgage 15 49.13% 3 14 3 15 3

Emergency Financial Assistance for utilities 16 48.54% 4 15 4 16 4

Psychosocial Support services group counseling to help cope with HIV 17 42.61% 10 17 8 18 19

Medical Nutritional Counseling 18 42.11% 8 19 9 17 8

Legal Services (to help you work through a problem obtaining services/benefits, outline advance directives or establish guardianships)

19 41.07% 7 18 6 19 14

Permanency Planning legal help with writing your will 20 40.00% 6 20 5 20 16

Home Health Care 21 35.61% 24 21 22 25 26

Treatment Adherence Counseling - help understanding your medications from someone other than a health professional

22 34.33% 22 25 24 20 21

Home and Community-based Health Services home aides and assistants 23 33.16% 22 23 20 26 25

Rehabilitation Services 24 31.96% 20 26 18 24 23

(For Women) Outpatient OB/Gyn Care visits 25 31.78% 30 24 33 27 29

Outreach to help you get HIV tested and into HIV medical care 25 31.78% 27 22 25 28 31

Outpatient Substance Abuse Treatment 27 31.07% 25 27 26 23 24

Substance Abuse Services - Residential 28 28.84% 26 28 29 22 22

Respite Care for Adults (Activities during day) 29 21.19% 27 29 27 29 28

Translation or Interpretation 30 20.48% 31 30 29 31 32

Hospice Services 31 18.52% 29 31 27 30 29

Child Care while at a medical or other appointment 32 10.51% 34 32 32 33 32

Child Assessment and Early Intervention 33 10.20% 31 33 29 33 32

(Out of Care Only) Early Intervention to help you get into HIV medical care

34 15.91% 31 n/a n/a 31 27

Respite Care for HIV positive Children 35 3.30% 35 34 34 35 35

*Services tied for fifth place

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CORE SERVICES

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(OUTPATIENT) AMBULATORY MEDICAL CARE (OAMC) The provision of professional diagnostic and therapeutic services rendered by a physician, physician's assistant, clinical nurse specialist, or nurse practitioner in an outpatient setting. Services include diagnostic testing, early intervention and risk assessment, preventive care and screening, practitioner examination, medical history taking, diagnosis and treatment of common physical and mental conditions, prescribing and managing medication therapy, education and counseling on health issues, well-baby care, continuing care and management of chronic conditions, and referral to and provision of specialty care (includes all medical subspecialties). Primary medical care for the treatment of HIV infection includes the provision of care that is consistent with the Public Health Service's guidelines. Such care must include access to antiretroviral and other drug therapies, including prophylaxis and treatment of opportunistic infections and combination antiretroviral therapies. It should be noted that the following services are presented in this section:

 HIV Outpatient Medical Care

 Medical Care from a Specialist referred by your HIV doctor (i.e., heart, skin, diabetes, other specialist)

 (For women) Outpatient OB/GYN Care Visits

 Child Assessment and Early Intervention HIV OUTPATIENT MEDICAL CARE Consumer Survey Results HIV Outpatient Medical Care was ranked number two in need by all survey respondents; HIV Outpatient Medical Care was ranked first in need by in-care and second in need by out-of-care consumers. It ranked eighteenth in unfulfilled need. This is an improvement from eleventh in unfulfilled need in 2013.

 In-care consumers ranked it twentieth in unfulfilled need.

 It is the twelfth ranked unfulfilled need for out-of-care. Consumer Service Needs and Barriers Considering the need for HIV Medical Care among the total consumer survey sample:

 77% had a need that is easily met.

 23% had a need for this service that is met with difficulty.

 34% had an unfulfilled need.

 Less than 1% did not respond. In-care consumers were using HIV Medical Care and report:

 79% found it easy to get, while

 20% found it hard or somewhat hard to get. Thirty-seven percent of out-of-care consumers had not used HIV Medical Care for at least 12 months.

 While 40% identified an unfulfilled need for HIV Medical Care, 60% did not have a need for it.

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Considering Priority Populations’ needs for HIV Outpatient Medical Care:

 In-care Black/African-American men and women and in-care MSM had the largest percentages reporting no need for HIV Outpatient Medical Care (excludes populations with small “n”s responding).

 Among respondents that had not used this service in the past 12 months, out-of-care Black/African American men and women and out-of-care MSM had the highest unmet need (excludes populations with small “n”s responding).

 In-care Hispanic men and women and in-care MSM had the largest percentage with their need met easily.

Table 5.2 Service Need

HIV Outpatient Medical Care

2016 Need Met Easily Need Met Hard Need Met No

Response Need Not Met No Need

Population # % # % # % # % # %

Total 370 76.8% 109 22.6% 3 0.6% 63 34.2% 121 65.8%

In-Care 275 79.3% 69 19.9% 3 0.9% 27 28.4% 68 71.6%

Out-Of-Care 95 70.4% 40 29.6% - 0.0% 36 40.4% 53 59.6%

Need Met "Hard" includes respondents who said it was hard or somewhat hard to obtain the service.

Need Met percentages are based on respondents who have used the service in the last 12 months. Total n = 482, In-Care n = 347, Out-Of-Care n = 135

Need Not Met Percentages are based on respondents who have NOT used the service in the last 12 months. Total n = 184, In-Care n = 95, Out-Of-Care n = 89

Table 5.3

Service Need by Priority Population HIV Outpatient Medical Care

2016 Need Met Easily Need Met Hard Need Met No

Response Need Not Met No Need

Population # % # % # % # % # %

Black/African- American Men & Women

In-Care 158 76.3% 48 23.2% 1 0.5% 10 25.0% 30 75.0%

Out-Of-Care 44 66.7% 22 33.3% - 0.0% 23 39.7% 35 60.3%

Hispanic/Latino (of any Race) Men & Women

In-Care 40 81.6% 9 18.4% - 0.0% 8 34.8% 15 65.2%

Out-Of-Care 18 69.2% 8 30.8% - 0.0% 2 28.6% 5 71.4%

MSM In-Care 137 83.0% 27 16.4% 1 0.6% 13 27.7% 34 72.3%

Out-Of-Care 51 71.8% 20 28.2% - 0.0% 20 37.0% 34 63.0%

Age 13-24 In-Care 2 66.7% 1 33.3% - 0.0% - 0.0% 2 100.0%

Out-Of-Care - 0.0% 6 100.0% - 0.0% 3 37.5% 5 62.5%

Transgender In-Care 5 62.5% 3 37.5% - 0.0% 1 100.0% - 0.0%

Out-Of-Care - 0.0% - 0.0% 2 100.0% 3 100.0% - 0.0%

Need Met "Hard" includes respondents who said it was hard or somewhat hard to obtain the service. Need Met percentages are based on respondents who have used the service in the last 12 months. Need Not Met Percentages are based on respondents who have NOT used the service in the last 12 months.

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In-Care Barriers to Care In-care consumers were then asked to identify barriers relating to HIV Medical Care based on a list of potential problems. In-care consumers were asked, “Why was it hard for you to get HIV Medical Care?” Four hundred fifty-seven in-care consumers responded to this question with 57% indicating it was not hard to get medical care. Those with problems cited the following issues:

 “The amount of time it takes at the clinic” was identified by 69 consumers (15%).

 Paperwork needed was identified by 59 respondents (13%).

 Transportation was a problem for 55 respondents (12%).

 “The time it takes to get an appointment” was a potential problem for 43 consumers (9%).

 “I cannot afford the co-pays, deductibles, and other costs of treatment” was reported by 41 respondents (9%).

Table 5.4

Potential Problems HIV Outpatient Medical Care

In the past year, why was it hard for you to get HIV Medical Care? (Check all that apply) In-Care

# %

It was not hard to get medical care 258 56.5%

Amount of time it takes at the clinic 69 15.1%

Paperwork needed 59 12.9%

I do not have transportation so it's hard to get there 55 12.0%

I cannot afford the co-pays, deductibles, and other costs of treatments and medicines 41 9.0%

The time it takes to get an appointment 43 9.4%

No weekend hours 40 8.8%

No evening hours (after 5 pm) 33 7.2%

I have to miss work to go to medical appointments 34 7.4%

Sometimes I do not feel well enough to go to my appointment 26 5.7%

I am afraid of being seen at the clinic 17 3.7%

I do not feel mentally able to deal with the treatment 8 1.8%

The clinic only treats HIV and no other medical conditions 12 2.6%

It is too hard to follow the medical advice 1 0.2%

The staff does not understand my culture 5 1.1%

I am in a domestic violence/sexual assault situation 2 0.4%

The staff does not speak my language 1 0.2%

Other 22 4.8%

In-Care n = 457; Out-of-Care n = 240; Combined In-Care/Out-of-Care n = 697

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Priority Populations’ Service Needs and Barriers to Care Comparing the problems with HIV Medical Care identified by the Priority Populations finds:

 Black/African-American men and women, Hispanic/Latinos, and MSM all consider “the amount of time it takes at the clinic” the biggest problem with HIV Medical Care.

 Youth report being seen at the clinic as the top barrier.

 Paperwork needed was cited among Black/African-American men and women, Hispanic/Latinos, MSM, and Transgender consumers as the second biggest problem.

 “The staff doesn’t understand my culture” tied for the most cited barrier to receiving HIV Medical Care for Transgender respondents

 “Paperwork” ranked in the top five problems for all populations.

Table 5.5 Potential Problems by Priority Populations

HIV Outpatient Medical Care

In the past year, why was it hard for you to get HIV Medical Care? (Check all that apply)

# %

Total Sample In-Care (n=457)

Amount of time it takes at the clinic 69 15.1%

Paperwork needed 59 12.9%

I do not have transportation so it's hard to get there 55 12.0%

The time it takes to get an appointment 43 9.4%

I cannot afford the co-pays, deductibles, and other costs of treatments and medicines 41 9.0%

African American Men & Women In-Care (n=253)

Amount of time it takes at the clinic 43 17.0%

Paperwork needed 35 13.8%

I do not have transportation so it's hard to get there 32 12.6%

The time it takes to get an appointment 27 10.7%

I cannot afford the co-pays, deductibles, and other costs of treatments and medicines 26 10.3%

Hispanic Men & Women In-Care (n=76)

Amount of time it takes at the clinic 11 14.5%

Paperwork needed 8 10.5%

I do not have transportation so it's hard to get there 8 10.5%

I cannot afford the co-pays, deductibles, and other costs of treatments and medicines 7 9.2%

Sometimes I do not feel well enough to go to my appointment 7 9.2%

MSM In-Care (n=216)

Amount of time it takes at the clinic 37 17.1%

Paperwork needed 31 14.4%

I do not have transportation so it's hard to get there 30 13.9%

The time it takes to get an appointment 24 11.1%

I cannot afford the co-pays, deductibles, and other costs of treatments and medicines 22 10.2%

Youth Age 13 to 24: In Care / Out of Care (n=22)

I am afraid of being seen at the clinic 5 22.7%

Amount of time it takes at the clinic 4 18.2%

Paperwork needed 4 18.2%

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In the past year, why was it hard for you to get HIV Medical Care? (Check all that apply)

# %

The time it takes to get an appointment 4 18.2%

No weekend hours 4 18.2%

Transgender In Care / Out of Care (n=15)

Amount of time it takes at the clinic 3 20.0%

Paperwork needed 3 20.0%

The time it takes to get an appointment 3 20.0%

The staff does not understand my culture 3 20.0%

I cannot afford the co-pays, deductibles, and other costs of treatments and medicines 2 13.3%

Focus Group and Key Informant Interviews The comments presented below represent the beliefs, opinions and experiences of the participants.

 The biggest problem at the hospital is access to care within 2 weeks or less; that is very difficult. It takes 2-4 weeks and we tend to lose people in the meantime.

 We have all of our same doctors, they are just not working as many days as they were. We’re trying but it’s still hard to get enough doctors to get them seen right away, especially since most of our doctors work part-time.

 Structural factors are keeping people from coming into care such as high rates of poverty and lack of access to general medical care.

 Services for transgender persons are severely lacking. Only 2 doctors in the area treat transgender persons, so they have zero resources.

 Those that get into care sometimes receive very good care, particularly with doctors who are HIV certified, or if they are in a huge climate where there are FQHC’s (Federally Qualified Health Centers)

 It looks like we have isolated HIV so much that only those in the HIV field know much about HIV, but general doctors and Medical Centers, are just not that well-informed.

 Wait time to see the doctor and often needing to see a social worker once before seeing a doctor; anyone associated with RWHAP should be able to make a doctor’s appointment at any point.

 When it comes to medical, it would be good to get clients an appointment even if the system is not ready to provide them with treatment medication, but its important for the client to feel engaged.

 I don’t want to go to _________, because everyone knows ________ is for HIV. It’s a big stigma.

 Coordination of care is an issue between specialty HIV providers, especially when those providers are doing primary care. I think in our area it’s reasonably addressed because the clinic providers are willing to accept primary care as part of the realm of HIV.

 Sometimes, even though the prevention worker does their job and gets them an appointment, the agency they referred the patient to can’t see them (within the required time frame) because they don’t have an open appointment, so that’s a capacity issue.

 For the newly diagnosed, another barrier is we need more understanding and open providers – some patients will make every effort to get to that appointment; they’re 5 minutes late, the provider will not see them. Timeliness of appointments and some sort of generosity in timing. And understanding that this patient made every effort to get here on time – they took six buses to get there and their last bus was delayed and now they’re late for the appointment, and the doctor will allow them point of entry.

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Provider Capacity Survey Results

Six RWHAP agencies provided HIV Outpatient Medical Care. All reported a waiting time for a first appointment of approximately 3 to 18 days. Four providers reported, collectively, an additional capacity of 1,079 annually. Three providers reported providing services to targeted populations. Provider Resource Inventory Seventeen agencies in the 2015-2016 Source Book1 offered HIV Outpatient Medical Care (including PCP, OB/GYN, and/or care from a specialist). Comparison between 2016, 2013, 2010, and 2007 Comprehensive Needs Assessments Historically, the total number of HRSA core and support services varies based upon policy decisions. As such, in order to assess fluctuation of rank of importance, the rankings for 2016 and 2013 are assigned quartiles and compared in that manner. In both 2016 and 2013 HIV Outpatient Medical Care was ranked second in total need. Among in-care respondents, HIV Outpatient Medical Care became the number one service need in 2016, an increase from second place in 2013. It has remained ranked second among out-of-care consumers in 2016. Unfulfilled need rank fell from the second quartile in 2013 into the third quartile in 2016 for all respondents.

1 The 2015-2016 Source Book is inclusive of providers offering services that are part of the Planning Council’s continuum of care as well as supplemental information from: the 2015 HIV Handbook of North Dallas (developed by the Parkland Health and Hospital System HIV Services Department), information received from rural RWHAP agencies about their referral partners, and service providers from the RWPC 2013 Resource Inventory that are not captured in the aforementioned sources but are still in operation.

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Table 5.6 Total Need and Unfulfilled Need Service Rank 2007, 2010, 2013, 2016

HIV Outpatient Medical Care

HIV Outpatient Change from

’07-‘16

Total Sample

Total Need Rank

2016 2

(1) 2013 2

2010 2

2007 1

Unfulfilled Need Rank

2016 18

(13) 2013 11

2010 10

2007 5

In-Care

Total Need Rank

2016 1

0 2013 2

2010 1

2007 1

Unfulfilled Need Rank

2016 20

3 2013 12

2010 23

2007 23

Out-of-Care

Total Need Rank

2016 2

1 2013 2

2010 5

2007 3

Unfulfilled Need Rank

2016 12

(11) 2013 12

2010 5

2007 1

Gap Analysis The need for HIV Outpatient Medical Care was ranked second by the total sample in terms of need and eighteenth in terms of unfulfilled need. Among out-of-care respondents, HIV Outpatient Medical Care ranked second for need and twelfth in unfulfilled need. Among in-care respondents, HIV Outpatient Medical Care ranked first in terms of need, and ranked twentieth in terms of unfulfilled need. Over one-third (34%) of consumer survey respondents reported an unmet need for HIV Outpatient Medical Care. Common barriers cited by survey respondents from each Priority Population included “the amount of time it takes at the clinic,” “paperwork needed,” “I do not have transportation so it’s hard to get there,” and “the time it takes to get an appointment.” Key Informant and Focus Group discussions focused on the wait times for appointments to access care.

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MEDICAL CARE FROM A SPECIALIST Consumer Survey Results Medical Care from a Specialist ranked seventh in need by all survey respondents. Medical Care from a Specialist ranked sixth in need by in-care and tenth by out-of-care respondents. It ranked twelfth in unfulfilled need among all survey respondents from sixteenth in 2013.

 In-care consumers ranked it eleventh in unfulfilled need.

 Out-of-care consumers ranked it sixteenth in unfulfilled need. Consumer Service Needs and Barriers Considering the need for Medical Care from a Specialist among the total consumer survey sample:

 73% had their need easily met.

 27% had their need met with difficulty.

 22% had an unfulfilled need. In-care consumers were using Medical Care from a Specialist and reported:

 74% found it easy to get, while

 26% found it hard or somewhat hard to get. Thirty-one percent of out-of-care consumers reported Medical Care from a Specialist as hard or somewhat hard to get.

 While 22% identified an unfulfilled need for Medical Care from a Specialist; 78% did not have a need for it.

Considering Priority Populations’ needs for Medical Care from a Specialist:

 In-care MSM and out-of-care Youth had the largest percentages reporting no need for Medical Care from a Specialist (excludes populations with small “n”s responding).

 Among respondents that had not used this service in the past 12 months, out-of-care African American men and women reported the highest unmet need (excludes populations with small “n”s responding).

 In-care MSM and out-of-care African American men and women had the largest percentage with their need met easily (excludes populations with small “n”s responding).

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Table 5.7 Service Need

Medical Care from a Specialist

2016 Need Met Easily Need Met Hard Need Met No Response Need Not Met No Need

Population # % # % # % # % # %

Total 234 72.9% 87 27.1% - 0.0% 76 22.4% 264 77.6%

In-Care 178 74.2% 62 25.8% - 0.0% 44 22.3% 153 77.7%

Out-Of-Care 56 69.1% 25 30.9% - 0.0% 32 22.4% 111 77.6%

Need Met "Hard" includes respondents who said it was hard or somewhat hard to obtain the service. Need Met percentages are based on respondents who have used the service in the last 12 months. Total n = 321, In-Care n = 240, Out-Of-Care n = 81 Need Not Met Percentages are based on respondents who have NOT used the service in the last 12 months. Total n = 340, In-Care n = 197, Out-Of-Care n = 143

Table 5.8 Service Need by Priority Population

Medical Care from a Specialist

2016 Need Met

Easily Need Met Hard Need Met

No Response Need Not Met No Need

Population # % # % # % # % # %

Black/African-American Men & Women

In-Care 106 74.6% 36 25.4% - 0.0% 27 26.0% 77 74.0%

Out-Of-Care 34 77.3% 10 22.7% - 0.0% 17 21.3% 63 78.8%

Hispanic/Latino (of any Race) Men & Women

In-Care 24 68.6% 11 31.4% - 0.0% 9 24.3% 28 75.7%

Out-Of-Care 8 53.3% 7 46.7% - 0.0% 4 22.2% 14 77.8%

MSM In-Care 84 78.5% 23 21.5% - 0.0% 17 16.5% 86 83.5%

Out-Of-Care 31 68.9% 14 31.1% - 0.0% 16 20.0% 64 80.0%

Age 13-24 In-Care 1 100.0% - 0.0% - 0.0% 1 25.0% 3 75.0%

Out-Of-Care - 0.0% 1 100.0% - 0.0% 2 15.4% 11 84.6%

Transgender In-Care 3 50.0% 3 50.0% - 0.0% 3 100.0% - 0.0%

Out-Of-Care - 0.0% - 0.0% - 0.0% 2 40.0% 3 60.0%

Need Met "Hard" includes respondents who said it was hard or somewhat hard to obtain the service. Need Met percentages are based on respondents you have used the service in the last 12 months.

Need Not Met Percentages are based on respondents who have NOT used the service in the last 12 months.

Comparing the barriers to receiving Medical Care from a Specialist identified by the Priority Populations finds:

 Black/African-American men and women, Hispanic/Latinos, and MSM all considered “difficult to get appointment” the greatest barrier to Medical Care from a Specialist.

 High co-pay was cited among 20% of Transgender, 18% of MSM, 16% of Black/African-American men and women, and 8% of Hispanic/Latinos as the second biggest problem.

 All populations cited “Other” barriers.

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Table 5.9 Need Barriers to Care by Priority Population

Medical Care from a Specialist

2016 Barrier 1 Barrier 2 Barrier 3 Barrier 4 Total

Population # % # % # % # % #

Total n = 76 32 42.1% 6 7.9% 12 15.8% 26 34.2% 76

Black/African-American Men & Women (n=44) 18 40.9% 4 9.1% 7 15.9% 15 34.1% 44

Hispanic/Latino (of any Race) Men & Women (n=13) 6 46.2% 1 7.7% 1 7.7% 5 38.5% 13

MSM (n=33) 13 39.4% 4 12.1% 6 18.2% 10 30.3% 33

Age 13-24 (n=3) 1 33.3% 0 0.0% 0 0.0% 2 66.7% 3

Transgender (n=5) 0 0.0% 1 20.0% 1 20.0% 3 60.0% 5

Note: Responses are combined In-Care/Out-Of-Care

Barrier 1: Difficult to get appointment Barrier 3: High co-pay

Barrier 2: Service Not Available Barrier 4: Other

Focus Group and Key Informant Interviews The comments presented below represent the beliefs, opinions and experiences of the participants.

 The population living with HIV is aging, so there are significant co-morbidities we worry about in the aging HIV community including cardiovascular health and cancer prevention – screening and surveillance are huge and that’s going to require a multidisciplinary approach to a lot of different things the HIV provider can’t provide.

 There are a lot of clinics providing primary care, but the problem is when it comes to seniors there is a lack of providers for complex care, especially if that includes HIV.

 Clients are afraid to speak out about what services are not being offered one-on-one with the doctor. I feel like I don’t have accessibility to my doctor’s time, especially because of my co-morbid conditions.

Provider Capacity Survey Results Three RWHAP agencies provided specialty care. One provider reported a waiting time for a first appointment of approximately 12 days. Two providers reported, collectively, an additional capacity of 850 annually. No respondents reported providing services to targeted populations. Provider Resource Inventory Seventeen agencies in the 2015-2016 Source Book offer HIV Outpatient Medical Care (including PCP, OB/GYN, and/or care from a specialist). Comparison between 2016, 2013, 2010, and 2007 Comprehensive Needs Assessments Historically, the total number of HRSA core and support services varies based upon policy decisions. As such, in order to assess fluctuation of rank of importance, the rankings for 2016 and 2013 are assigned quartiles and compared in that manner.

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In both 2016 and 2013, Medical Care from a Specialist was ranked in the first quartile of total need. The unfulfilled need rank was 16th out of 27 services in 2013, falling in the third quartile. In 2016, unfulfilled need rank was 12th out of 35 services, falling in the second quartile.

Table 5.10 Total Need and Unfulfilled Need Service Rank 2007, 2010, 2013, 2016

Medical Care from a Specialist

Medical Care from a Specialist referred by your HIV doctor Change from

’07-‘16

Total Sample

Total Need Rank

2016 7

(7) 2013 6

2010 9

2007 0

Unfulfilled Need Rank

2016 12

(12) 2013 16

2010 13

2007 0

In-Care

Total Need Rank

2016 6

(6) 2013 6

2010 9

2007 0

Unfulfilled Need Rank

2016 11

(11) 2013 15

2010 10

2007 0

Out-of-Care

Total Need Rank

2016 10

(10) 2013 7

2010 17

2007 0

Unfulfilled Need Rank

2016 16

(16) 2013 14

2010 16

2007 0

PRIMARY MEDICAL CARE FOR GENERAL MEDICAL CARE NOT RELATED TO HIV Primary Medical Care for General Medical Care not Related to HIV was the sixth most cited of 20 services from which consumers were asked to select “the five services they needed most”. Twenty-five percent, 175 respondents, included Primary Medical Care for General Medical Care not Related to HIV in their top five service needs.

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CHRONIC DISEASE ISSUES PLWH are living longer and developing chronic diseases. Consumer survey participants were asked whether they had been diagnosed with diabetes, high blood pressure, or heart disease. The results show:

 High blood pressure was the most commonly treated illness with 26% of respondents receiving medical treatment for this condition.

 Among Priority Populations, Transgender (47%), MSM (24%), and African-American men and women (24%) had the highest percentages receiving treatment for high blood pressure.

 Nine percent of survey respondents reported being treated for diabetes.  Excluding small sample size of Transgender (20%, n=3), Hispanic/Latino men and

women report the highest percentage of diabetes at 12%.

 Heart disease treatment was reported by 6% of survey participants.

Table 5.11 Chronic Disease Issues

Received Medical Treatment for Diabetes, High blood pressure, or Heart disease

Total Sample In-Care (n=457) Out-of-Care (n=240) Total Sample (n=697)

Diabetes 51 11.2% 12 5.0% 63 9.0%

High Blood Pressure 135 29.5% 43 17.9% 178 25.5%

Heart Disease 34 7.4% 8 3.3% 42 6.0%

African American Men & Women In-Care (n=253) Out-of-Care (n=134) Total Sample (n=387)

Diabetes 22 8.7% 5 3.7% 27 7.0%

High Blood Pressure 68 26.9% 25 18.7% 93 24.0%

Heart Disease 14 5.5% 6 4.5% 20 5.2%

Hispanic Men & Women In-Care (n=76) Out-of-Care (n=37) Total Sample (n=113)

Diabetes 10 13.2% 4 10.8% 14 12.4%

High Blood Pressure 19 25.0% 4 10.8% 23 20.4%

Heart Disease 7 9.2% 0 0.0% 7 6.2%

MSM In-Care (n=216) Out-of-Care (n=113) Total Sample (n=349)

Diabetes 22 10.2% 2 1.5% 24 6.9%

High Blood Pressure 65 30.1% 19 14.3% 84 24.1%

Heart Disease 17 7.9% 3 2.3% 20 5.7%

Youth Age 13 to 24: In-Care (n=7) Out-of-Care (n=15) Total Sample (n=22)

Diabetes 0 0.0% 0 0.0% 0 0.0%

High Blood Pressure 0 0.0% 0 0.0% 0 0.0%

Heart Disease 0 0.0% 0 0.0% 0 0.0%

Transgender In-Care (n=10) Out-of-Care (n=5) Total Sample (n=15)

Diabetes 3 30.0% 0 0.0% 3 20.0%

High Blood Pressure 5 50.0% 2 40.0% 7 46.7%

Heart Disease 1 10.0% 0 0.0% 1 6.7%

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Gap Analysis Medical Care from a Specialist Referred by your HIV Doctor (i.e., heart, skin, diabetes, other specialist) ranked seventh in total need and twelfth in terms of unfulfilled need. Among out-of-care respondents, Medical Care from a Specialist Referred by your HIV Doctor (i.e., heart, skin, diabetes, other specialist) ranked tenth and sixteenth for unfulfilled need. Among in-care respondents, Medical Care from a Specialist Referred by your HIV Doctor (i.e., heart, skin, diabetes, other specialist) ranked sixth in terms of total need and eleventh in unfulfilled need. Among those who had not used specialty care in the past 12 months, 22% of respondents reported an unmet need for the service. OUTPATIENT OB/GYN CARE Consumer Survey Results Female respondents ranked Outpatient OB/GYN twenty-fifth in need; outpatient female respondents ranked OB/GYN twenty-fourth in need by in-care and twenty-seventh in need. This service ranked thirtieth in unfulfilled need among female respondents.

 In-care females ranked it thirty-third in unfulfilled need.

 It was the twenty-ninth ranked unfulfilled need for out-of-care female respondents. Consumer Service Needs and Barriers Considering the need for Outpatient OB/GYN care among women in the consumer survey sample:

 91% had a need that is easily met.

 10% had a need for this service that is met with difficulty.

 42% had an unfulfilled need. In-care consumers who used Outpatient OB/GYN care reported:

 91% found it easy to get, while

 10% found it hard or somewhat hard to get. Ten percent of out-of-care consumers reported Outpatient OB/GYN care as hard or somewhat hard to receive.

 While 42% identified an unfulfilled need for Outpatient OB/GYN care, 58% did not have a need for it.

Considering Priority Populations’ needs for Outpatient OB/GYN care:

 In-care Black/African-American women had the largest percentages reporting no need for Outpatient OB/GYN care.

 Among respondents that had not used this service in the past 12 months, out-of-care Hispanic/Latino women (75%) and out-of-care African American women (55%) had the highest unmet need.

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 Among respondents that used this service in the past 12 months, out-of-care African American men and women had the largest percentage with their need met easily (excludes populations with small “n”s responding).

Table 5.12

Service Need Outpatient OB/GYN Care

2016 Need Met Easily Need Met Hard Need Met

No Response Need Not Met No Need

Population # % # % # % # % # %

Total 95 90.5% 10 9.5% - 0.0% 18 41.9% 25 58.1%

In-Care 67 90.5% 7 9.5% - 0.0% 8 34.8% 15 65.2%

Out-Of-Care 28 90.3% 3 9.7% - 0.0% 10 50.0% 10 50.0%

Need Met "Hard" includes respondents who said it was hard or somewhat hard to obtain the service. Need Met percentages are based on respondents who have used the service in the last 12 months. Total n = 105, In-Care n = 74, Out-Of-Care n = 31

Need Not Met Percentages are based on respondents who have NOT used the service in the last 12 months. Total n = 43, In- Care n = 23, Out-Of-Care n = 20

Table 5.13

Service Need by Priority Population Outpatient OB/GYN Care

2016 Need Met

Easily Need Met

Hard Need Met

No Response Need Not

Met No Need

Population # % # % # % # % # %

Black/African- American Women

In-Care 53 94.6% 3 5.4% - 0.0% 5 38.5% 8 61.5%

Out-Of-Care 19 100.0% - 0.0% - 0.0% 6 54.5% 5 45.5%

Hispanic/Latino Women (of any Race)

In-Care 4 66.7% 2 33.3% - 0.0% 1 50.0% 1 50.0%

Out-Of-Care 6 85.7% 1 14.3% - 0.0% 3 75.0% 1 25.0%

Age 13-24 Women In-Care 1 100.0% - 0.0% - 0.0% - 0.0% - 0.0%

Out-Of-Care 1 100.0% - 0.0% - 0.0% 0.0% - 0.0%

Need Met "Hard" includes respondents who said it was hard or somewhat hard to obtain the service. Need Met percentages are based on respondents who have used the service in the last 12 months.

Need Not Met Percentages are based on respondents who have NOT used the service in the last 12 months.

Comparing the barriers to receiving Outpatient OB/GYN care identified by the Priority Populations finds:

 Black/African-American women and Hispanic/Latino women considered “difficult to get appointment” the biggest barrier to Outpatient OB/GYN care.

 “Want to see a female doctor” and “high co-pay” were also barriers to Outpatient OB/GYN care.

 “Other” barriers were cited.

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Table 5.14 Barriers to Care

Outpatient OB/GYN Care by Priority Population

2016 Barrier 1 Barrier 2 Barrier 3 Barrier 4 Total

Population # % # % # % # % #

Total n = 18 5 27.8% 1 5.6% 2 11.1% 10 55.6% 18

Black/African-American Women (n=11) 4 36.4% 0 0.0% 0 0.0% 7 63.6% 11

Hispanic/Latino (of any Race) Women (n=4) 1 25.0% 1 25.0% 1 25.0% 1 25.0% 4

Age 13-24 (n=0) 0 N/A 0 N/A 0 N/A 0 N/A 0

Note: Responses are combined In-Care/Out-Of-Care - Women Only

Barrier 1: Difficult to get appointment Barrier 3: Want to See a Female Doctor

Barrier 2: High co-pay Barrier 4: Other

Focus Group and Key Informant Interviews The comments presented below represent the belief, opinions, and experiences of the participants.

 A lot of moms come to the clinic while they’re pregnant but you may not see them again until they’re pregnant again (1-2 years later); a lot has to do with stigma. A lot of time their partner doesn’t know they are positive. And, if they don’t live near one of our other clinics, they do not want to come to _____. I think they sometimes feel they would rather not be in care than come to (), where they will be readily identified as being HIV positive.

 Women sometimes do not come back for care because they are busy taking care of others and put that before themselves or their health.

 Hard to keep women engaged because there is nothing carved out for them because there’s no money for that

 More emphasis on overall health, women’s health and family health, and at the same time let them know about HIV testing.

Provider Capacity Survey Results Four RWHAP agencies provide (for women) Outpatient OB/GYN Care visits. All four providers reported a waiting time for a first appointment of approximately 3 to 12 days. All four providers reported, collectively, an additional capacity of 715 annually. No respondents reported providing services to targeted populations. Provider Resource Inventory Seventeen agencies in the 2015-2016 Source Book offered HIV Outpatient Medical Care (including PCP, OB/GYN, and/or care from a specialist).

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Comparison between 2016, 2013, 2010, and 2007 Comprehensive Needs Assessments No historical data.

Table 5.15 Total Need and Unfulfilled Need Service Rank 2007, 2010, 2013, 2016

Outpatient OB/GYN Care

(For Women) Outpatient OB/GYN Care visits Change from

’07-‘16

Total Sample

Total Need Rank

2016 25

No Historical Data 2013

2010

2007

Unfulfilled Need Rank

2016 30

No Historical Data 2013

2010

2007

In-Care

Total Need Rank

2016 24

No Historical Data 2013

2010

2007

Unfulfilled Need Rank

2016 33

No Historical Data 2013

2010

2007

Out-of-Care

Total Need Rank

2016 27

No Historical Data 2013

2010

2007

Unfulfilled Need Rank

2016 29

No Historical Data 2013

2010

2007

Gap Analysis Survey respondents ranked Outpatient OB/GYN Care visits twenty-fifth in need among the total sample and thirtieth in terms of unfulfilled need. Out-of-care respondents ranked Outpatient OB/GYN Care visits twenty-seventh in total need and twenty-ninth in unfulfilled need. Among in-care respondents, Outpatient OB/GYN Care visits ranked twenty-fourth in terms of total need and thirty-third in unfulfilled need. Among women who had not used OB/GYN services within the past 12 months, 42% reported an unmet need for the service.

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CHILD ASSESSMENT AND EARLY INTERVENTION Consumer Survey Results “Child Assessment and Early Intervention” was the thirty-third ranked overall service need, and the thirty-first most frequently identified unfulfilled need. In addition, in-care consumers ranked it thirty-third in overall need and twenty-ninth in unfulfilled need, while out-of-care consumers ranked it thirty-third in need and thirty-second in unfulfilled need. Consumer Service Needs and Barriers Eighteen percent of those who had not used this service in the past 12 months reported an unmet net.

 80% of in-care consumers reported their need for Child Assessment and Early Intervention as easily met.

 Considering service need by Priority Populations:  In-care African-American men and women have largest percentage (26%) with an

unmet need for this service.

Table 5.16 Service Need

Child Assessment and Early Intervention

2016 Need Met Easily Need Met Hard Need Met

No Response Need Not Met No Need

Population # % # % # % # % # %

Total 12 80.0% 3 20.0% - 0.0% 15 17.6% 70 82.4%

In-Care 9 81.8% 2 18.2% - 0.0% 11 19.3% 46 80.7%

Out-Of-Care 3 75.0% 1 25.0% - 0.0% 4 14.3% 24 85.7%

Need Met "Hard" includes respondents who said it was hard or somewhat hard to obtain the service. Need Met percentages are based on respondents who have used the service in the last 12 months. Total n = 15, In- Care n = 11, Out-Of-Care n = 4 Need Not Met Percentages are based on respondents who have NOT used the service in the last 12 months. Total n = 85, In-Care n = 57, Out-Of-Care n = 28

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Table 5.17 Service Need by Priority Population

Child Assessment and Early Intervention

2016 Need Met

Easily Need Met

Hard Need Met

No Response Need Not Met No Need

Population # % # % # % # % # %

Black/African- American Men & Women

In-Care 7 87.5% 1 12.5% - 0.0% 10 25.6% 29 74.4%

Out-Of-Care 1 100.0% - 0.0% - 0.0% 3 16.7% 15 83.3%

Hispanic/Latino (of any Race) Men & Women

In-Care 2 66.7% 1 33.3% - 0.0% 1 8.3% 11 91.7%

Out-Of-Care 1 50.0% 1 50.0% - 0.0% - 0.0% 5 100.0%

MSM In-Care 2 66.7% 1 33.3% - 0.0% 1 11.1% 8 88.9%

Out-Of-Care - 0.0% - 0.0% - 0.0% - 0.0% 7 100.0%

Age 13-24 In-Care - 0.0% - 0.0% - 0.0% - 0.0% - 0.0%

Out-Of-Care - 0.0% - 0.0% - 0.0% - 0.0% 1 100.0%

Transgender In-Care - 0.0% - 0.0% - 0.0% - 0.0% 1 100.0%

Out-Of-Care - 0.0% - 0.0% - 0.0% - 0.0% - 0.0%

Need Met "Hard" includes respondents who said it was hard or somewhat hard to obtain the service. Need Met percentages are based on respondents who have used the service in the last 12 months.

Need Not Met Percentages are based on respondents who have NOT used the service in the last 12 months.

A total of 15 consumers identified barriers to care for Child Assessment and Intervention Services.

 The most frequent barrier to accessing Child Assessment and Intervention Services is “Don’t know about this service”, identified by 87% of consumers that reported barriers to this service.

 7% indicated “don’t qualify” and 7% indicated an “Other” barrier.

Table 5.18 Service Need Barriers to Care by Priority Population

Child Assessment and Early Intervention

2016 Barrier 1 Barrier 2 Barrier 3 Total

Population # % # % # % #

Total n = 15 13 86.7% 1 6.7% 1 6.7% 15

Black/African-American Men & Women (n=13) 11 84.6% 1 7.7% 1 7.7% 13

Hispanic/Latino (of any Race) Men & Women (n=1) 1 100.0% 0 0.0% 0 0.0% 1

MSM (n=1) 1 100.0% 0 0.0% 0 0.0% 1

Age 13-24 (n=0) 0 N/A 0 N/A 0 N/A 0

Transgender (n=0) 0 N/A 0 N/A 0 N/A 0

Note: Responses are combined In-Care/Out-Of-Care

Barrier 1: Don't know about this service Barrier 3: Other

Barrier 2: Don't qualify

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Focus Group and Key Informant Interviews No discussion of Child Intervention and Early Assessment occurred in the Focus Groups or throughout the Key Informant Interview process. Provider Capacity Survey Results No RWHAP agencies reported providing Child Assessment and Early Intervention. Provider Resource Inventory Seven agencies in the 2015-2016 Source Book offer Child Assessment and Early Intervention. Comparison between 2016, 2013, 2010, and 2007 Comprehensive Needs Assessments There are no historical data for this service category.

Table 5.19 Total Need and Unfulfilled Need Service Rank 2007, 2010, 2013, 2016

Child Assessment and Early Intervention

Child Assessment and Early Intervention Change from ’07-‘16

Total Sample

Total Need Rank

2016 33

No Historical Data 2013

2010

2007

Unfulfilled Need Rank

2016 31

No Historical Data 2013

2010

2007

In-Care

Total Need Rank

2016 33

No Historical Data 2013

2010

2007

Unfulfilled Need Rank

2016 29

No Historical Data 2013

2010

2007

Out-of-Care

Total Need Rank

2016 33

No Historical Data 2013

2010

2007

Unfulfilled Need Rank

2016 32

No Historical Data 2013

2010

2007

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Gap Analysis Child Assessment and Early Intervention ranked thirty-third in total need in the Total Sample, and ranked thirty-first in terms of unfulfilled need in the Total Sample. Among out-of-care respondents, Child Assessment and Early Intervention ranked thirty-third for total need and ranked thirty-second for unfulfilled need. Among in-care respondents, Child Assessment and Early Intervention ranked thirty- third in terms of total need, and was ranked twenty-ninth in terms of unfulfilled need. Two percent of consumer survey respondents reported an unmet need for the service. Recommendations Wait times for appointments, access to care and paperwork burdens continue to be the barriers most often cited in the information gathered in the survey, Focus Groups and Key Informant Interviews. 1. Linkage to care should occur within two business days; clinical resources and adequate funding

must be available to accommodate this goal.

 Monitor the capacity of funded providers to accommodate the demand for services (e.g., physician and advance practitioner availability).

 Ensure adequate level of funding is made available to support providers offering outpatient medical care.

2. Reduce the consumer paperwork burden to ensure that information regarding eligibility and

updates can be accessed by all providers via ARIES, eliminating the need for multiple intakes or enrollments at each agency.

 Make the “consent to share information” a requirement for the receipt of services, as has been used successfully elsewhere

 Educate consumers as to the benefits they will accrue as a result of information sharing. 3. Give consideration to extending the 30-day timeframe for referrals. 4. Ensure providers offer evening and weekend hours and provide access to bilingual staff. 5. Consider the value of one-stop outpatient medical care for consumers (e.g. clinics that can

provide on-site access to HIV, primary, specialty and OB/GYN care for patients) in funding services.

6. Ensure that all HIV medical clinics that do not have on-site access to the full range of medical

care and maintain strong working relationships and referral ties to necessary primary and care providers.

7. Encourage providers to devote time during the clinic visit to stress the importance of remaining

in care even when patients are feeling well.

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Quality of care is one of HRSA’s highest priorities, especially for Outpatient Ambulatory Medical Care. 8. Place sufficient importance on quality management programs, utilizing the National Quality

Center’s varied technical assistance programs to their fullest potential. 9. Consider a collaborative of HIV medical providers to review HAB indicators of quality, and

especially those related to the HIV Care Continuum, namely viral load suppression and medical visit frequency. Establish quality improvement initiatives such as Plan-Do-Study-Act (PDSA) to add structure to the monitoring of these indicators.

10. Establish an annual quality management plan with stated goals and objectives related to

retention in care and viral load suppression.

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AIDS DRUG ASSISTANCE PROGRAM (ADAP) AND AIDS PHARMACEUTICAL ASSISTANCE (LOCAL) HRSA Definition AIDS Drug Assistance Program (ADAP) is a state-administered program authorized under Part B of the RWHAP to provide FDA-approved medications to low-income clients with HIV disease who have no coverage or limited health care coverage. ADAPs may also use program funds to purchase health insurance for eligible clients and for services that enhance access to, adherence to, and monitoring of antiretroviral therapy. RWHAP ADAP recipients must conduct a cost effectiveness analysis to ensure that purchasing health insurance is cost effective compared to the cost of medications in the aggregate. Eligible ADAP clients must be living with HIV and meet income and other eligibility criteria as established by the state AIDS Pharmaceutical Assistance services fall into two categories, based on RWHAP Part A, B, C or D funding.

 Local Pharmaceutical Assistance Program (LPAP) is operated by a RWHAP Part A or B recipient or subrecipient as a supplemental means of providing medication assistance when an ADAP has a restricted formulary, waiting list and/or restricted financial eligibility criteria.

 Community Pharmaceutical Assistance Program is provided by a RWHAP Part C or D recipient for the provision of long-term medication assistance to eligible clients in the absence of any other resources. The medication assistance must be greater than 90 days.

The following services are presented in this section:

 Help paying for prescription medications.

 Help paying for medications and prescriptions/other pharmaceutical assistance. HELP PAYING FOR PRESCRIPTION MEDICATIONS Consumer Survey Results Help Paying for Prescription Medicine was the fourth ranked overall service need, and the thirteenth most frequently identified unfulfilled need. In addition, in-care consumers ranked it fourth in overall need and thirteenth in unfulfilled need, while out-of-care consumers ranked it third in need and sixth in unfulfilled need. Consumer Service Needs and Barriers Help paying for prescription medications was used only by in-care consumers, but 36% of out-of-care respondents reported an unfulfilled need for it.

 Nearly 72% of in-care consumers reported their need for help paying for medications/prescriptions is being easily met; 28% had an unfulfilled need.

 Considering service need by Priority Populations:  Out-of-care African-American men and women tied with in-care Hispanic/Latino men

and women for having the largest percentage (36%) with an unmet need for this service.

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 32% of out-of-care MSM reported an unmet need for this service. A total of 74 consumers identified barriers to care for paying for prescription medicine.

 The most frequent barrier to accessing help in paying for medications and prescriptions was “I didn’t know about this service,” identified by over 50% of consumers.

 This was followed by “high co-pays and deductibles,” “didn’t qualify” identified by 15% of those with barriers.

 19% indicated an “Other” barrier.

Table 5.20 Service Need

Help Paying for Medications/Prescriptions

2016 Need Met

Easily Need Met

Hard Need Met No

Response Need Not Met No Need

Population # % # % # % # % # %

Total Total 281 71.3% 113 28.7% - 0.0% 74 27.7% 193 72.3%

In-Care 200 71.9% 78 28.1% - 0.0% 35 22.0% 124 78.0%

Out-Of-Care 81 69.8% 35 30.2% - 0.0% 39 36.1% 69 63.9%

Need Met "Hard" includes respondents who said it was hard or somewhat hard to obtain the service. Need Met percentages are based on respondents who have used the service in the last 12 months. Total n = 394, In- Care n = 278, Out-Of-Care n = 116 Need Not Met Percentages are based on respondents who have NOT used the service in the last 12 months. Total n = 267, In-Care n = 159, Out-Of-Care n = 108

Table 5.21

Service Need by Priority Population Help Paying for Medications/Prescriptions

2016 Need Met

Easily Need Met

Hard Need Met

No Response Need Not

Met No Need

Population # % # % # % # % # %

Black/African-American Men & Women

In-Care 107 70.4% 45 29.6% - 0.0% 18 19.1% 76 80.9%

Out-Of-Care 41 68.3% 19 31.7% - 0.0% 23 35.9% 41 64.1%

Hispanic/Latino (of any Race) Men & Women

In-Care 34 68.0% 16 32.0% - 0.0% 8 36.4% 14 63.6%

Out-Of-Care 13 65.0% 7 35.0% - 0.0% 3 23.1% 10 76.9%

MSM In-Care 107 75.4% 35 24.6% - 0.0% 16 23.5% 52 76.5%

Out-Of-Care 52 75.4% 17 24.6% - 0.0% 18 32.1% 38 67.9%

Age 13-24 In-Care 1 25.0% 3 75.0% - 0.0% 1 100.0% - 0.0%

Out-Of-Care 1 25.0% 3 75.0% - 0.0% 2 20.0% 8 80.0%

Transgender In-Care 1 16.7% 5 83.3% - 0.0% 1 33.3% 2 66.7%

Out-Of-Care - 0.0% - 0.0% 1 100.0% 1 25.0% 3 75.0%

Need Met "Hard" includes respondents who said it was hard or somewhat hard to obtain the service. Need Met percentages are based on respondents who have used the service in the last 12 months. Need Not Met Percentages are based on respondents who have NOT used the service in the last 12 months.

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Table 5.22 Barriers to Care

Help Paying for Prescription Medications by Priority Population

2016 Barrier 1 Barrier 2 Barrier 3 Barrier 4 Total

Population # % # % # % # % #

Total n = 74 38 51.4% 11 14.9% 11 14.9% 14 18.9% 74

Black/African-American Men & Women (n=41) 24 58.5% 5 12.2% 5 12.2% 7 17.1% 41

Hispanic/Latino (of any Race) Men & Women (n=11) 4 36.4% 2 18.2% 4 36.4% 1 9.1% 11

MSM (n=34) 19 55.9% 4 11.8% 3 8.8% 8 23.5% 34

Age 13-24 (n=3) 0 0.0% 0 0.0% 0 0.0% 3 100.0% 3

Transgender (n=2) 1 50.0% 0 0.0% 1 50.0% 0 0.0% 2

Note: Responses are combined In-Care/Out-Of-Care

Barrier 1: Didn't know about the service Barrier 3: Didn't qualify

Barrier 2: High co pay and deductible Barrier 4: Other

HELP PAYING FOR MEDICATIONS AND PRESCRIPTIONS/OTHER PHARMACEUTICAL ASSISTANCE Consumer Survey Results Help Paying for Medicines and Prescriptions/Other Pharmaceuticals was ranked sixth in overall service need and eleventh in unfulfilled need.

 In-care consumers ranked it seventh in overall need and twelfth in unfulfilled need.

 Out-of-care consumers ranked it fifth2 in service need and seventh in unfulfilled need. Consumer Service Needs and Barriers Seventy-four percent of respondents reported their needs easily met, and 24% had an unmet need.

 33% of out-of-care consumers had an unmet need for this service.

 Among Priority Populations:  36% of out-of-care Hispanic/Latino men and women had an unmet need.  32% of out-of-care African-American men and women reported an unfulfilled need.  26% of out-of-care MSMs and 25% (1) Transgender respondents also cited an unmet

need.

2 Medical Case Management and Help Paying for Prescription Medicines/Other Pharmaceutical Assistance tied for fifth place in total need among out-of-care consumers.

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Table 5.23 Service Need

Help Paying for Medications and Prescriptions/Other Pharmaceutical Assistance:

2016 Need Met

Easily Need Met

Hard Need Met No

Response Need Not Met No Need

Population # % # % # % # % # %

Total Total 259 74.4% 89 25.6% - 0.0% 77 24.8% 233 75.2%

In-Care 184 75.7% 59 24.3% - 0.0% 39 20.2% 154 79.8%

Out-Of-Care 75 71.4% 30 28.6% - 0.0% 38 32.5% 79 67.5%

Need Met "Hard" includes respondents who said it was hard or somewhat hard to obtain the service. Need Met percentages are based on respondents who have used the service in the last 12 months. Total n = 348, In-Care n = 243, Out-Of-Care n = 105 Need Not Met Percentages are based on respondents who have NOT used the service in the last 12 months. Total n = 310, In-Care n = 193, Out-Of-Care n = 117

Table 5.24

Service Need by Priority Population Help Paying for Medications and Prescriptions/Other Pharmaceutical Assistance

2016 Need Met

Easily Need Met

Hard Need Met No

Response Need Not

Met No Need

Population # % # % # % # % # %

Black/African-American In-Care 97 72.9% 6 27.1% - 0.0% 20 17.9% 92 82.1%

Men & Women Out-Of-Care 35 70.0% 15 30.0% - 0.0% 23 31.5% 50 68.5%

Hispanic/Latino (of any Race) Men & Women

In-Care 29 65.9% 15 34.1% - 0.0% 7 25.0% 21 75.0%

Out-Of-Care 13 59.1% 9 40.9% - 0.0% 4 36.4% 7 63.6%

MSM In-Care 94 77.7% 27 22.3% - 0.0% 19 21.3% 70 78.7%

Out-Of-Care 47 83.9% 9 16.1% - 0.0% 18 26.9% 49 73.1%

Age 13-24 In-Care 2 66.7% 1 33.3% - 0.0% - 0.0% 2 100.0%

Out-Of-Care 1 33.3% 2 66.7% - 0.0% 2 18.2% 9 81.8%

Transgender In-Care 2 50.0% 2 50.0% - 0.0% 1 25.0% 3 75.0%

Out-Of-Care - 0.0% - 0.0% 1 100.0% 2 50.0% 2 50.0%

Need Met "Hard" includes respondents who said it was hard or somewhat hard to obtain the service. Need Met percentages are based on respondents who have used the service in the last 12 months. Need Not Met Percentages are based on respondents who have NOT used the service in the last 12 months.

Of a total of 77 respondents who identified a barrier for this service:

 The most frequent barrier cited was “I didn’t know about the service,” (48%).

 This was followed by “I didn’t qualify,” (25%).

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Table 5.25

Barriers to Care Help Paying for Medications and Prescriptions/Other Pharmaceutical Assistance

by Priority Populations

2016 Barrier 1 Barrier 2 Barrier 3 Barrier 4 Total

Population # % # % # % # % #

Total n = 77 37 48.1% 10 13.0% 19 24.7% 11 14.3% 77

Black/African-American Men & Women (n=43) 20 46.5% 6 14.0% 11 25.6% 6 14.0% 43

Hispanic/Latino (of any Race) Men & Women (n=11) 5 45.5% 0 0.0% 6 54.5% 0 0.0% 11

MSM (n=37) 23 62.2% 4 10.8% 5 13.5% 5 13.5% 37

Age 13-24 (n=2) 1 50.0% 0 0.0% 0 0.0% 1 50.0% 2

Transgender (n=3) 2 66.7% 0 0.0% 1 33.3% 0 0.0% 3

Note: Responses are combined In-Care/Out-Of-Care

Barrier 1: Didn't know about the service Barrier 3: Didn't qualify

Barrier 2: High co pay and deductible Barrier 4: Other

Provider Inventory Six RWHAP agencies provided Pharmaceutical Assistance. Two providers reported a waiting time for a first appointment of approximately 7 to 12 days. Two providers reported, collectively, an additional capacity of 315 annually. No respondents reported providing services to targeted populations. Resource Inventory Twenty-two agencies in the 2015-2016 Source Book offered “Help Paying for Prescription Medications”

(ADAP and/or Local).

Comparison between 2016, 2013, 2010, and 2007 Comprehensive Needs Assessments The total need for Help Paying for Prescription Medications was the fourth highest ranked service in 2016 and 2013. In 2010 and 2007, the service was the fifth highest ranked. The unfulfilled need for the service was ranked thirteenth in 2016, and eighth in 2013. In 2010 the service was ranked seventh. In 2007 the service was ranked twelfth. In 2016, Help Paying for Prescription Medications/Other Pharmaceutical Assistance ranked sixth highest. In 2013, it ranked fourth, and ranked fifth both in 2010 and 2007. The unfulfilled need for this service ranked eleventh in 2016, and eighth in 2013. In 2010 it ranked eleventh and in 2007 it was ranked twelfth.

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Table 5.26

Total Need and Unfulfilled Need Service Rank 2007, 2010, 2013, 2016 Help Paying for Prescription Medications

Help Paying for

Prescription Medications

Change from

’07-‘16

Total Sample

Total Need Rank

2016 4

1 2013 4

2010 5

2007 5

Unfulfilled Need Rank

2016 13

(1) 2013 8

2010 7

2007 12

In-Care

Total Need Rank

2016 4

(3) 2013 2

2010 1

2007 1

Unfulfilled Need Rank

2016 13

10 2013 12

2010 23

2007 23

Out-of-Care

Total Need Rank

2016 3

7 2013 4

2010 3

2007 10

Unfulfilled Need Rank

2016 6

2 2013 9

2010 3

2007 8

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The total need for Help Paying for Medications and Prescriptions/Other Pharmaceutical Assistance was the sixth highest ranked service in 2016. In 2013 the service was the fourth highest ranked. The unfulfilled need for the service was ranked eleventh in 2016. In 2013 the service was ranked eighth.

Table 5.27

Total Need and Unfulfilled Need Service Rank 2007, 2010, 2013, 2016 Help Paying for Medications and Prescriptions/Other Pharmaceutical Assistance

Help Paying for Prescription

Medications/Other Pharmaceutical

Assistance

Change from

’07-‘16

Total Sample

Total Need Rank

2016 6

(1) 2013 4

2010 5

2007 5

Unfulfilled Need Rank

2016 11

1 2013 8

2010 7

2007 12

In-Care

Total Need Rank

2016 7

(3) 2013 4

2010 5

2007 4

Unfulfilled Need Rank

2016 12

7 2013 7

2010 13

2007 19

Out-of-Care

Total Need Rank

2016 5

5 2013 4

2010 3

2007 10

Unfulfilled Need Rank

2016 7

1 2013 9

2010 3

2007 8

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Gap Analysis Help Paying for Prescription Medications was the fourth ranked service, and the thirteenth ranked unfulfilled need. Help Paying for Prescription Medications ranked sixth in overall need and eleventh in unfulfilled need. Seventy-four percent of respondents had their needs easily met, and 26% had an unfulfilled need. Seventy-one percent of consumers found the service easy to access and 26% had an unfulfilled need. Respondents identified lack of knowledge of the services as the largest barrier to receiving pharmaceutical assistance. This was followed by high co-pays and deductibles and “I didn’t qualify.” Medication assistance is one of the most needed services, and like many of the top-rated need services, there is limited expansion capacity within the funded agencies to fulfill needs. Recommendations 1. Access to medications is essential for reducing individual and community-wide viral loads.

 Ensure, via regular in-service training, that medical case managers are knowledgeable about medication assistance programs and eligibility requirements.

 Medication compliance is a significant barrier to care for the working poor and those with limited insurance coverage. Non-RWHAP programs, such as pharmaceutical company relief programs, may be available on a limited basis. Maintaining up-to-date information about such opportunities is essential and should be communicated to all clinical personnel and medical case managers.

 Clinical personnel and medical case managers should continually educate their consumers about the importance of medication adherence, how to access medication assistance and what to do when their prescriptions run out.

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EARLY INTERVENTION SERVICES (EIS) HRSA Definition Early Intervention Services (EIS) include counseling individuals with respect to HIV/AIDS; testing (including test to confirm the presence of the disease, tests to diagnose to the extent of immune deficiency, tests to provide information on appropriate therapeutic measures); referrals; other clinical and diagnostic services regarding HIV/AIDS; periodic medical evaluations for individuals with HIV/AIDS; and providing therapeutic measures. Consumer Survey Results Early intervention services were ranked only by out-of-care consumers. Among the out-of-care, it was ranked thirty-first in terms of overall need. Consumer Service Needs and Barriers Early Intervention Services were not needed by over half of out-of-care survey respondents.

 21% of out-of-care respondents report their need for Early Intervention Services is not being met.

 Among Priority Populations, Black/African-Americans (13) had the largest percentage (27%) reporting an unfulfilled need for EIS.

 Youth 13-24 (7) had the largest percentage reporting no need for EIS (100%), followed by MSM (4) (89.5%), and Hispanic/Latinos (1) (83%).

 In terms of barriers, over 50% of the sample “didn’t know about this service,” and a third “were not sure they understand it,” (the service).

Table 5.28

Service Need Early Intervention to Help you Get into HIV Medical Care

Out-of-Care Only

2016 Need Met

Easily Need Met

Hard Need Met No

Response Need Not

Met No Need

Population # % # % # % # % # %

Total Total 3 50.0% 3 50.0% - 0.0% 15 21.1% 56 78.9%

Out-Of-Care 3 50.0% 3 50.0% - 0.0% 15 21.1% 56 78.9%

Need Met "Hard" includes respondents who said it was hard or somewhat hard to obtain the service. Need Met percentages are based on respondents who have used the service in the last 12 months. Total n = 6, Out-Of- Care n = 6 Need Not Met Percentages are based on respondents who have NOT used the service in the last 12 months. Total n = 71, Out-Of-Care n = 71

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Table 5.29 Service Need by Priority Population

Early Intervention to Help you Get into HIV Medical Care Out-of-Care Only

2016 Need Met

Easily Need Met

Hard Need Met No

Response Need Not Met No Need

Population # % # % # % # % # %

Black/African-American Men & Women Out-Of-Care 1 33.3% 2 66.7% - 0.0% 13 27.1% 35 72.9%

Hispanic/Latino (of any Race) Men & Women Out-Of-Care - 0.0% - 0.0% - 0.0% 1 16.7% 5 83.3%

MSM Out-Of-Care 3 60.0% 2 40.0% - 0.0% 4 10.5% 34 89.5%

Age 13-24 Out-Of-Care 2 66.7% 1 33.3% - 0.0% - 0.0% 7 100.0%

Transgender Out-Of-Care - 0.0% - 0.0% - 0.0% 2 50.0% 2 50.0%

Need Met "Hard" includes respondents who said it was hard or somewhat hard to obtain the service. Need Met percentages are based on respondents who have used the service in the last 12 months. Need Not Met Percentages are based on respondents who have NOT used the service in the last 12 months.

Table 5.30

Barriers to Care by Priority Population Early Intervention to Help you Get into HIV Medical Care

Out-of-Care Only

2016 Barrier 1 Barrier 2 Barrier 3 Total

Population # % # % # % #

Total n = 15 8 53.3% 5 33.3% 2 13.3% 15

Black/African-American Men & Women (n=13) 7 53.8% 4 30.8% 2 15.4% 13

Hispanic/Latino (of any Race) Men & Women (n=1) 1 100.0% 0 0.0% 0 0.0% 1

MSM (n=4) 2 50.0% 1 25.0% 1 25.0% 4

Age 13-24 (n=0) 0 N/A 0 N/A 0 N/A 0

Transgender (n=2) 2 100.0% 0 0.0% 0 0.0% 2

Note: Responses are Out-Of-Care Respondents Only

Barrier 1: Did not know about this service Barrier 3: Other

Barrier 2: Not sure I understand it

Provider Inventory Two RWHAP agencies provided Early Intervention Service. Two reported a waiting time for a first appointment of approximately 4 to 18 days. One provider reported an additional capacity of 100 clients annually. One provider reported providing services to targeted populations.

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Resource Inventory Twenty-nine agencies in the 2015-2016 Source Book offer HIV Outreach & Early Intervention Services (including HIV Testing). Comparison between 2016, 2013, 2010, and 2007 Comprehensive Needs Assessments In 2016, the total need for Early Intervention Services among out-of-care consumers was the thirty-first highest ranked service. In 2013 the need for Early Intervention was ranked twenty-fourth, and in 2010 EIS was ranked sixth. In 2016, the unfulfilled need for Early Intervention Services among out-of-care consumers was the twenty-seventh highest ranked service. In 2013 and 2010 the unfulfilled need ranked twenty-second and sixth, respectively.

Table 5.31 Total Need and Unfulfilled Need Service Rank 2007, 2010, 2013, 2016

Early Intervention to help you get into HIV medical care Out-of-Care Only

(Out of Care Only) Early Intervention

to help you get into HIV medical care

Change from

’07-‘16

Out-of-Care

Total Need Rank

2016 31

(27) 2013 24

2010 6

2007 4

Unfulfilled Need Rank

2016 27

(23) 2013 22

2010 6

2007 4

Gap Analysis Early Intervention Services were ranked among the lowest service needs by those out-of-care (thirty- first). It was also ranked twenty-seventh in terms of unmet need. Information obtained from provider Focus Groups suggest that post-test counseling is not always provided or provided effectively. Barriers to the service include cultural differences between agency personnel and those at risk, and a lack of awareness or indifference to the impact of structural as well as cultural barriers, and the paperwork burden. Services must be delivered in a culturally competent manner to ensure the individual receives referral and linkage to essential services. Additionally, to the extent possible, serious attention needs to be given to alleviating the paperwork burden at the local level. The current system has capacity for 75 additional patients.

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Recommendations Recommendations for 2016 are similar to those in 2013, and include: 1. Linking newly diagnosed PLWH with medical care immediately after diagnosis is the critical first

step to maintaining PLWH in the care system. It was noted throughout the survey that those who linked to care within one to three months of diagnosis were more likely to be in care than those who linked to care three months or later. Effective post-test counseling, easy referral to (a) intake, (b) HIV medical care and (c) other needed services are essential.

 Continue to fund and support this essential service.

 Evaluate and enhance the effectiveness of current counseling and testing systems in moving newly diagnosed into care.

 Work with counseling and testing providers to re-emphasize the importance of early intervention and counseling to keep PLWH in care.

 Provide education for community agencies, emergency departments, and others providing HIV test results in order to improve understanding, enhance communication, and effectively link with early intervention services.

2. Establish a task force to evaluate and make recommendations to: (1) methods, including

checklists, permissions to share information that would alleviate the paperwork burden and standards for providing EIS; and (2) make recommendations to the Planning Council, Recipient and Administrative Agent to implement these changes.

3. Consider a structured regional patient navigation program that coordinates outreach, EIS and

medical providers to enhance effectiveness of these important components of linkage to care.

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HEALTH INSURANCE PREMIUM AND COST SHARING ASSISTANCE FOR LOW INCOME INDIVIDUALS HRSA Definition Health Insurance Premium and Cost Sharing Assistance provides financial assistance for eligible clients living with HIV to maintain continuity of health insurance or to receive medical and pharmacy benefits under a health care coverage program. To use RWHAP funds for health insurance premium and cost- sharing assistance, a RWHAP Part recipient must implement a methodology that incorporates the following requirements:

 RWHAP Part recipients must ensure that clients are buying health coverage that, at a minimum, includes at least one drug in each close of core antiretroviral therapeutics from the Department of Health and Human Services (HHS) treatment guidelines along with appropriate HIV outpatient/ambulatory health services.

 RWHAP Part recipients must assess and compare the aggregate cost of paying for the health coverage option versus paying for the aggregate full cost for medications and other appropriate HIV outpatient/ambulatory health services, and allocate funding to Health Insurance Premium and Cost Sharing Assistance only when determined to be cost effective.

The service provision consists of help with your health premiums, co-pays, or deductibles. Consumer Survey Results Fifty-one percent of the consumers surveyed report having insurance.

 Medicare was the most frequent type of insurance, with 38% of those enrolled in insurance plans reporting this coverage.

 30% had Medicaid.

 17% had private insurance.

 11% had Parkland HealthFirst

 < 1% had COBRA.

Table 5.32

Insurance Coverage

In-Care Out-of-Care Total

Do you have health insurance that covers your HIV medical care? (Note: RWHAP is NOT insurance) # % # % # %

Yes 257 56.2% 95 39.6% 352 50.5%

No 200 43.8% 145 60.4% 345 49.5%

Total 457 100.0% 240 100.0% 697 100.0%

In-Care n = 457; Out-of-Care n = 240; Combined In-Care/Out-of-Care n = 697

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Table 5.33

Type of Health Insurance

In-Care Out-of-Care Total

Do you have health insurance that covers your HIV medical care? (Note: RWHAP is NOT insurance) # % # % # %

Medicaid 75 29.2% 32 33.7% 107 30.4%

Medicare 105 40.9% 29 30.5% 134 38.1%

Parkland HealthFirst 23 8.9% 17 17.9% 40 11.4%

Private Insurance 42 16.3% 16 16.8% 58 16.5%

COBRA 3 1.2% 0 0.0% 3 0.9%

Other 9 3.5% 1 1.1% 10 2.8%

Total 257 100.0% 95 100.0% 352 100.0%

In-Care n = 257; Out-of-Care n = 95; Combined In-Care/Out-of-Care n = 352

Consumer Service Needs and Barriers Responses indicate that 65% of consumers had their need for this service met easily. A total of 24% of consumer survey respondents had an unfulfilled need for this service, and 76% had no need for this service.

 Overall, out-of-care consumers had a higher unmet need for this service.  This was true for all Priority Populations except Hispanic/Latino men and women. In

this case, both in-care and out-of-care consumers had similar unfulfilled needs --- 20% and 19%, respectively.

Table 5.34

Service Need Help with your Health Insurance Premium, Co-Pay or Deductible

2016 Population

Need Met Easily Need Met Hard Need Met No

Response Need Not Met No Need

# % # % # % # % # %

Total Total 171 65.3% 91 34.7% - 0.0% 95 24.3% 296 75.7%

In-Care 125 66.5% 63 33.5% - 0.0% 51 20.7% 195 79.3%

Out-Of-Care 46 62.2% 28 37.8% - 0.0% 44 30.3% 101 69.7%

Need Met "Hard" includes respondents who said it was hard or somewhat hard to obtain the service. Need Met percentages are based on respondents who have used the service in the last 12 months. Total n = 262, In-Care n = 188, Out-Of-Care n = 74 Need Not Met Percentages are based on respondents who have NOT used the service in the last 12 months. Total n = 391, In- Care n = 246, Out-Of-Care n = 145

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Table 5.35

Service Need by Priority Population Help with Your Health Insurance Premium, Co-Pay or Deductible

2016 Need Met

Easily Need Met

Hard

Need Met No

Response Need Not

Met No Need

Population # % # % # % # % # %

Black/African-American Men & Women

In-Care 70 59.3% 48 40.7% - 0.0% 28 22.0% 99 78.0%

Out-Of-Care 22 57.9% 16 42.1% - 0.0% 30 36.1% 53 63.9%

Hispanic/Latino (of any Race) Men & Women

In-Care 15 71.4% 6 28.6% - 0.0% 10 20.4% 39 79.6%

Out-Of-Care 6 50.0% 6 50.0% - 0.0% 4 19.0% 17 81.0%

MSM In-Care 65 70.7% 27 29.3% - 0.0% 27 23.1% 90 76.9%

Out-Of-Care 26 68.4% 12 31.6% - 0.0% 24 28.6% 60 71.4%

Age 13-24 In-Care 1 50.0% 1 50.0% - 0.0% - 0.0% 1 100.0%

Out-Of-Care 1 33.3% 2 66.7% - 0.0% 4 36.4% 7 63.6%

Transgender In-Care 1 50.0% 1 50.0% - 0.0% 1 20.0% 4 80.0%

Out-Of-Care - 0.0% - 0.0% - 0.0% 3 60.0% 2 40.0%

Need Met "Hard" includes respondents who said it was hard or somewhat hard to obtain the service. Need Met percentages are based on respondents who have used the service in the last 12 months. Need Not Met Percentages are based on respondents who have NOT used the service in the last 12 months.

The greatest barrier was, “I did not know about the service,” identified by 61% of those with an unmet need. Another 22% “don’t know what to do about insurance.”

Table 5.36 Barriers to Care by Priority Population

Help with your Health Insurance Premium, Co-Pay or Deductible

2016 Barrier 1 Barrier 2 Barrier 3 Barrier 4 Total

Population # % # % # % # % #

Total n = 95 58 61.1% 5 5.3% 21 22.1% 11 11.6% 95

Black/African-American Men & Women (n=58) 35 60.3% 3 5.2% 13 22.4% 7 12.1% 58

Hispanic/Latino (of any Race) Men & Women (n=14) 11 78.6% 1 7.1% 1 7.1% 1 7.1% 14

MSM (n=51) 34 66.7% 2 3.9% 10 19.6% 5 9.8% 51

Age 13-24 (n=4) 1 25.0% 1 25.0% 0 0.0% 2 50.0% 4

Transgender (n=4) 3 75.0% 0 0.0% 0 0.0% 1 25.0% 4

Note: Responses are combined In-Care/Out-Of-Care

Barrier 1: Didn't know about the service Barrier 3: Don’t know what to do about insurance

Barrier 2: Don’t want any insurance Barrier 4: Other

RWHAP Planning Council of the Dallas Area 2016 Comprehensive HIV/AIDS Needs Assessment 5-SERVICE CATEGORIES

4/19/2017 5-43 New Solutions, Inc.

Provider Focus Group and Key Informant Interviews The comments presented below represent the belief, opinions, and experiences of Key Informants and Focus Group members. While indirectly related, the unintended consequence of the ACA provision to allow children up to the age of 26 remain on their parents’ insurance and the lack of Medicaid expansion were identified as barriers. Another issue related to the effective use of resources to provide financial support for co-pays and deductibles.

 Even though we have insurance support available, I think we could do a better job to make sure that those resources are effective . . . For example, we can do premium support to keep insurance going, but what if we can’t afford co-pays or deductibles for their labs or visits?

 Lack of Medicaid expansion.

 Texas has no Welfare System so you’re either disabled or you are not. The job market is tight so there’s a lack of financial support.

 The obvious issue is health insurance; it must be an issue for closeted young people on their parents’ insurance.

Provider Inventory Five RWHAP agencies provided Assistance with Co-Pays and Deductibles. Five providers reported a

waiting time for a first appointment of approximately 4 to 12 days. Five providers reported, collectively,

an additional capacity of 263 annually. No respondents reported providing services to targeted

populations.

Resource Inventory Six agencies in the 2015-2016 Source Book offered Help with Health Insurance Premiums, Co-Pays, or

Deductibles.

RWHAP Planning Council of the Dallas Area 2016 Comprehensive HIV/AIDS Needs Assessment 5-SERVICE CATEGORIES

4/19/2017 5-44 New Solutions, Inc.

Table 5.37

Total Need and Unfulfilled Need Service Rank 2007, 2010, 2013, 2016 Help with your Health Insurance Premium, Co-Pay or Deductible

Help paying for co- pays and

deductibles for HIV medical care visits and medications

Change from

’07-‘16

Total Sample

Total Need Rank

2016 9

(9) 2013 8

2010 7

2007 0

Unfulfilled Need Rank

2016 5

(5) 2013 10

2010 3

2007 0

In-Care

Total Need Rank

2016 9

(9) 2013 7

2010 8

2007 0

Unfulfilled Need Rank

2016 6

(6) 2013 10

2010 5

2007 0

Out-of-Care

Total Need Rank

2016 9

(9) 2013 9

2010 4

2007 0

Unfulfilled Need Rank

2016 4

(4) 2013 14

2010 2

2007 0

Gap Analysis Help in paying for continued insurance and paying for co-pays and deductibles ranked ninth in need and nineteenth in unfulfilled need. Twenty-four percent of consumers indicated an unmet need for this service. Based on survey responses from providers, capacity exists to serve additional consumers. According to the survey, the largest barrier to getting assistance with insurance premiums and co-pays and deductibles was the lack of consumer knowledge about the service.

RWHAP Planning Council of the Dallas Area 2016 Comprehensive HIV/AIDS Needs Assessment 5-SERVICE CATEGORIES

4/19/2017 5-45 New Solutions, Inc.

Recommendations The future of insurance coverage for many Texans, and all Americans, is uncertain due to the yet to be determined future of the ACA, and Medicaid. Regardless of the outcome, it is likely that eligibility changes will result and that education and training of case managers will be essential to ensure enrollment changes are handled in an expeditious manner. It is also expected that more individuals will lose coverage, placing additional burdens on the RWHAP Program. 1. Ensure that case managers are provided with education and training about the Affordable Care

Act (ACA) replacement options, enrollment procedures, benefits (physician, medication coverage), and nuances of new insurance coverage rules.

2. Ensure that case managers receive adequate education and training on any changes that would

impact consumers’ access to Medicaid. 3. Continue to provide funding for insurance continuation to eligible consumers in order to

maintain them in the care system and to reduce the burden of the increasing number of uninsured on the RWHAP Program.

 Provide detailed information to consumers about health insurance program requirements and necessary documentation.

 Ensure that case managers understand and receive education on benefits covered under this service, and any changes that may occur.

 Provide information about the insurance continuation program to private infectious disease practices so that they can refer patients in the event of job loss.

4. Continue to provide Financial Assistance for Co-Pays and Deductibles for both medical visits and

medications. 5. Ensure that insured patients are aware of funding to support often burdensome co-pays and

deductibles.

RWHAP Planning Council of the Dallas Area 2016 Comprehensive HIV/AIDS Needs Assessment 5-SERVICE CATEGORIES

4/19/2017 5-46 New Solutions, Inc.

HOME HEALTH CARE HRSA Definition Home Health Care is the provision of services in the home that are appropriate to a client’s needs and are performed by licensed professionals. Services must relate to the client’s HIV disease and may include:

 Administration of prescribed therapeutics (e.g. intravenous and aerosolized treatment, and parenteral feeding)

 Preventive and specialty care

 Wound care

 Routine diagnostics testing administered in the home

 Other medical therapies Consumer Survey Results Home Health Care was ranked twenty-first overall in terms of need and twenty-fourth in terms of unfulfilled need. Among in-care consumers, it ranked twenty-fourth in terms of need and twenty- second in unfulfilled needs. Out-of-care consumers ranked it twenty-fifth in need and twenty-sixth in unfulfilled need. Consumer Service Needs and Barriers Home Care Services were not needed by 93% of all survey respondents.

 Only 8% of survey respondents reported their needs not met.

 In terms of Priority Population, African-American men and women reported the highest percentage of needs not met (12%).

Table 5.38

Service Need Home Health Care

2016 Need Met

Easily Need Met Hard Need Met No

Response Need Not Met No Need

Population # % # % # % # % # %

Total Total 73 69.5% 32 30.5% - 0.0% 41 7.5% 507 92.5%

In-Care 53 68.8% 24 31.2% - 0.0% 25 7.0% 332 93.0%

Out-Of-Care 20 71.4% 8 28.6% - 0.0% 16 8.4% 175 91.6%

Need Met "Hard" includes respondents who said it was hard or somewhat hard to obtain the service. Need Met percentages are based on respondents who have used the service in the last 12 months. Total n = 105, In-Care n = 77, Out-Of-Care n = 28 Need Not Met Percentages are based on respondents who have NOT used the service in the last 12 months. Total n = 548, In-Care n = 357, Out-Of-Care n = 191

RWHAP Planning Council of the Dallas Area 2016 Comprehensive HIV/AIDS Needs Assessment 5-SERVICE CATEGORIES

4/19/2017 5-47 New Solutions, Inc.

Table 5.39

Service Need by Priority Population Home Health Care

2016 Need Met

Easily Need Met

Hard Need Met No

Response Need Not

Met No Need

Population # % # % # % # % # %

Black/African-American Men & Women

In-Care 38 70.4% 16 29.6% - 0.0% 17 8.9% 174 91.1%

Out-Of-Care 11 68.8% 5 31.3% - 0.0% 13 12.4% 92 87.6%

Hispanic/Latino (of any Race) Men & Women

In-Care 9 60.0% 6 40.0% - 0.0% 3 5.5% 52 94.5%

Out-Of-Care 3 50.0% 3 50.0% - 0.0% 2 7.4% 25 92.6%

MSM In-Care 25 69.4% 11 30.6% - 0.0% 8 4.6% 165 95.4%

Out-Of-Care 10 76.9% 3 23.1% - 0.0% 7 6.4% 102 93.6%

Age 13-24 In-Care - 0.0% - 0.0% - 0.0% - 0.0% 3 100.0%

Out-Of-Care 1 100.0% - 0.0% - 0.0% - 0.0% 13 100.0%

Transgender In-Care 1 50.0% 1 50.0% - 0.0% - 0.0% 5 100.0%

Out-Of-Care - 0.0% - 0.0% 1 100.0% - 0.0% 4 100.0%

Need Met "Hard" includes respondents who said it was hard or somewhat hard to obtain the service. Need Met percentages are based on respondents who have used the service in the last 12 months. Need Not Met Percentages are based on respondents who have NOT used the service in the last 12 months.

In terms of barriers, the biggest barrier cited by more than 49% of respondents was “Don’t know about this service.” “Don’t qualify” for the service was cited by 29% of respondents.

Table 5.40 Barriers to Care by Priority Population

Home Health Care

2016 Barrier 1 Barrier 2 Barrier 3 Barrier 4 Total

Population # % # % # % # % #

Total n = 41 20 48.8% 2 4.9% 12 29.3% 7 17.1% 41

Black/African-American Men & Women (n=30) 15 50.0% 1 3.3% 9 30.0% 5 16.7% 30

Hispanic/Latino (of any Race) Men & Women (n=5) 3 60.0% 1 20.0% 1 20.0% 0 0.0% 5

MSM (n=15) 10 66.7% 1 6.7% 2 13.3% 2 13.3% 15

Age 13-24 (n=0) 0 N/A 0 N/A 0 N/A 0 N/A 0

Transgender (n=0) 0 N/A 0 N/A 0 N/A 0 N/A 0

Note: Responses are combined In-Care/Out-Of-Care

Barrier 1: Don't know about this service Barrier 3: Don't Qualify

Barrier 2: Found An Easier Way To Get It Barrier 4: Other