Fulton County Department of Health and Wellness High Impact HIV Prevention Program

Transcription

1 Fulton County Department of Health and Wellness High Impact HIV Prevention Program City of Atlanta (Fulton/DeKalb Counties) Jurisdictional HIV Prevention Plan November 14, 2012 December 31, The City of Atlanta (Fulton/DeKalb Counties) Jurisdictional HIV Prevention Plan, covers multiple years (2012 ), is a written statement of need developed through a local collaborative process with other HIV/AIDS prevention, care, and treatment providers and agencies. 11/14/2012

2 Page1 Funding acknowledgement: The development of this document was made possible by funding from the Centers for Disease Control and Prevention Funding Announcement PS Comprehensive HIV Prevention for Health Departments, Grant No. U62 PS Disclaimer: This document was developed from September 2012 to November 2012 and submitted to the Centers for Disease Control and Prevention on November 14, Its contents reflect the data and information collected during this time period. The information used to develop the jurisdictional goals, strategies, and objectives were collected from community stakeholders that participated in several community engagement meetings and from the Jurisdiction s HIV Prevention Planning Group. For more information, contact: Fulton County Department of Health and Wellness High Impact HIV Prevention Program 99 Jesse Hill Jr., Drive S.E. Atlanta, GA Tel: (404) Fax: (404) Web:

3 Page2 Vision When every person in Fulton and DeKalb Counties is empowered to know their HIV status, and if HIVpositive, choose to access high quality care and treatment. Mission To achieve optimal HIV prevention and care services, by mobilizing partnerships and taking strategic action

4 Page3 TABLE OF CONTENTS LETTER OF CONCURRENCE 5 EXECUTIVE SUMMARY 9 INTRODUCTION 11 OVERVIEW OF THE HIV/AIDS EPIDEMIC IN GEORGIA 14 EPIDEMIOLOGY OF HIV/AIDS IN FULTON AND DEKALB COUNTIES 20 HIV PREVENTION, LINKAGE TO CARE AND TREATMENT SERVICES 26 A. Existing HIV Prevention, Linkage to Care and Treatment Resources and Services 27 B. Existing HIV Prevention, Linkage to Care and Treatment Interventions 29 C. HIV Prevention Interventions 30 D. Needs and Gaps in HIV Prevention, Linkage to Care and Treatment 31 PROCESS FOR DEVELOPING THE JURISDICTION HIV PREVENTION PLAN 34 FULTON/DEKALB COUNTIES JURISDICTIONAL HIV PREVENTION PLAN 38 REQUIRED PROGRAM PLAN COMPONENTS 39 A. HIV Testing in Healthcare and Non-healthcare settings 39 Required Intervention # 1: Opt-Out Screening for HIV in clinical settings 39 Required Intervention # 2: HIV Testing in non-clinical settings to identify Undiagnosed HIV infection 40 Required Intervention #10: Implement STI screening according to current guidelines for HIV-positive persons 42 Required Intervention #11: Implement prevention of perinatal transmission for HIV-positive persons 42 B. HIV Prevention with Positives 43 Required Intervention #6: Implement linkage to HIV care, treatment, and Prevention services for those testing HIV positive and not currently in care 43 Required Intervention #7: Implement interventions or strategies promoting retention in or re-engagement in care for HIV-positive persons 44 Required Intervention #8: Implement policies and procedures that will lead to the provision of antiretroviral treatment in accordance with current treatment guidelines for HIV-positive persons 44 Required Intervention #9: Implement interventions or strategies promoting adherence to antiretroviral medications for HIV-positive persons 45 Required Intervention #12: Implement ongoing partner services for

5 Page4 HIV-positive persons 46 C. Condom Distribution 47 Required Intervention # 3: Condom distribution prioritized to target HIV-positive persons at highest risk of acquiring HIV infection 47 D. Structural and Policy Initiatives 48 Required Intervention # 5: Efforts to change existing structures, policies, and regulations that are barriers to creating an environment for optimal HIV prevention, care and treatment 48 E. Other Supported Activities 50 Recommended Intervention #17: Clinic-wide or provider-delivered evidence-based HIV prevention interventions for HIV-positive clients and clients at highest risk of acquiring HIV 50 Required Intervention# 16: Promote HIV testing and condom use through social marketing 50 Required Intervention #4: Provision of Post-Exposure Prophylaxis to populations at greatest risk 51 Recommended Intervention #20: Integrated hepatitis, TB and STI testing, partner services, vaccination, and treatment for HIV infected persons, HIV-negative persons at highest risk of acquiring HIV, and injection drug users according to existing guidelines 52 NATIONAL HIV/AIDS STRATEGY NATIONAL STRATEGIC GOALS 53 ATTACHMENTS 59 Attachment A: List of Jurisdictional Planning Group 60 Attachment B: HIV Prevention Interventions 61 Attachment C: Community Engagement Report 64

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8 Page7 CONTRIBUTORS The Fulton/DeKalb Counties Jurisdictional HIV Prevention Plan development began with a series of community engagement meetings, hosted by Fulton County Department of Health and Wellness High Impact HIV Prevention Program and facilitated by HealthHIV, a national organization that provides capacity building and technical assistance for health departments, that focused on the local HIV epidemic and HIV prevention efforts in Fulton and DeKalb Counties, Georgia (Atlanta, GA). The meetings were convened to engage community stakeholders in the identification and prioritization of innovative HIV prevention strategies to address the high burden of HIV in the jurisdiction. A two-day community engagement, September 27 and 28, 2012, and a one-day follow-up meeting, October 17, 2012, was utilized to engage the community in the planning and development process. This document is the result of those meetings. The participants that played a critical role in the development of this plan are listed as follows: October 27 and 28, 2012 Aleta McClean Avery Wyatt Bedane Sentayehu Benjamin Moore Bentley Swenton Brandi Williams Charles Bazemore Charles Sperling Cheryl Courtney-Evans Darryl Richardson Dazon Dixon Diallo Denise Parker Edwin Blount Eulise White Gay Campbell-Welsh Hana Hawthone Harvinder Makkar Hilda Johnson Jacqueline Brown Jacqueline Muther Jane Kelly Jeselyn Rhodes John Malone Kandace Carty Katherine Lovell Kenya Taylor Khafre Kabif Latoya Wilkerson Laura Donnelly Levita Smith Lisa White Melanie Thompson Michael Banner Michael Demayo Michael Seabolt Mona Bennett Neil Griffith Nyrobi Moss Patricia Brown Patricia Parsons Patrick Daly Pete Starling Raymond Duke Reggie Batiste Rodriques Lambert Rudolph H. Carn Sean Webb Sheb Bonner Shelia Lenior Stacey Bolling Tabatha Greely Tarita Johnson Yolanda Miller Yotin Srivanjarean October 17, 2012 Andrea Jefferson-Saboor Bentley Swenton Bethe Odom Charles Sperling Cheryl Courtney-Evans Claressa Winston Darrell Waston Dea Varsovczky Laura Donnelly Eulise White Gay Campbell-Welsh Hilda Johnson Jacqueline Brown Jonte Carlisle Kandace Carty Kathy Whyte Kenya Taylor Latonya Wilkerson Leisha McKinley-Beach Loreen M. Krug Martin Becker Martina Rivora Michael Banner Michael Lumand Michael Seabolt Miko Jones Neena Smith-Bankhead Patricia Parsons Glenn Fitch Raymond Duke Robbyn Kistler Shelia Lenior Tarita Johnson Tequan Berry Verna Gaines Willie Pestarling Zina Age

9 Page8 AGENCY PARTICIPATION The list of participating agencies had never before participated in a structured HIV prevention and care services meeting for Fulton and DeKalb Counties. The list of participating agencies includes representation from all sectors and from non-traditional partners. They included, but not limited to, AIDS Service Organizations, Community-based Organizations, Academia, Federally Qualified Health Centers, and other agencies. The agencies that participated are listed as follows: October 27 and 28, 2012 AHRC, Inc. AID ATLANTA, Inc. AIDS Health Foundation City Wide Project AIDS Research Consortium of Atlanta (ARCA) Alpha and Omega HIV/AIDS Foundation ANIZ, Inc. ASHLIN Management Group Atlanta Medical Center Center for Pan Asian Community Services, Inc. DeKalb County Board of Health Empower Young Women Empowerment Resource Center, Inc. Essence of Hope, Inc. Georgia ADAP Pharmacy Georgia Department of Public Health/ HIV Program Georgia Department of Public Health/HIV Epidemiology Georgia STD Program Here's To Life, Inc. HOPWA, City of Atlanta NAESM, Inc. Project Open Hand Recovery Consultants of Atlanta, Inc. Ryan White - Part A Program SEATEC SisterLove, Inc. Saint Joseph Mercy Care STAND, Inc. The Edgewood Medical Center, Inc. T.I.L.T.T, Inc. (Transgender Individuals Living Their Truth) Tangu, Inc. Travelers Aid of Metropolitan Atlanta Inc. West End Medical Center Wholistic Stress Control Institute, Inc. October 17, 2012 Absolute Care Medical Center AID Atlanta, Inc. AIDS Research Consortium of Atlanta ANIZ, Inc. Atlanta Harm Reduction Coalition Black AIDS Institute Club Xhell Comiza Care Divinity Internal Medicine Essence of Hope, Inc. Georgia ADAP Pharmacy Georgia Department of Public Health Greater Than AIDS/Kasier Family Education Georgia STD Program Positive Impact, Inc. Recovery Consultants of Atlanta Ryan White Part A Program SEATEC Saint Joseph Mercy Care STAND, Inc. The Empowerment Resource Center, Inc. T.I.L.T.T, Inc. (Transgender Individuals Living Their Truth) UCHAPS Westcare Wholistic Stress Control Institute

10 Page9 EXECUTIVE SUMMARY This section provides a brief overview of the City of Atlanta (Fulton/DeKalb Counties) Jurisdictional HIV Prevention Plan and the process to development. The section highlights the local collaborative process with other HIV/AIDS prevention, care, and treatment providers and agencies

11 Page10 EXECUTIVE SUMMARY The City of Atlanta (Fulton/DeKalb Counties) Jurisdictional HIV Prevention Plan, covering multiple years (2012 ), is a written statement of need developed through a local collaborative process with other HIV/AIDS prevention, care, and treatment providers and agencies. The City of Atlanta (Fulton/DeKalb Counties) Jurisdictional HIV Prevention Plan reflects a discussion of existing resources, needs, and gaps for HIV prevention services, to include key features on how prevention services, interventions, and/or strategies are currently being used or delivered in the jurisdiction. 1 The plan includes a brief overview of epidemiological data, existing quantitative and qualitative information, and emerging trends/issues affecting HIV prevention services in the jurisdiction. The plan also highlights how existing prevention resources are allocated and disseminated locally to the areas with the greatest HIV burden and includes populations identified at greatest risk for HIV transmission and acquisition. The plan also discusses the responsible agency/group to carry out the goal, strategies, objectives, and relevant timelines. 2 The City of Atlanta (Fulton/DeKalb Counties) Jurisdictional HIV Prevention Plan is intended to serve as a best practice model and will be implemented in the manner that best fits the needs of the community. STI TB HIV AIDS MSA CDC MSM HRH NIR FOA EMA PCC IDP CD4 T-cell NHAS FPL Red Carpet Linkage Commonly Used Terms in this document Sexually Transmitted Infections Tuberculosis Human Immune Deficiency Virus Acquired Immune Deficiency Virus Metropolitan Statistical Area Centers for Disease Control and Prevention Men who have sex with men High Risk Heterosexual No Identified Risks Funding Opportunity Announcement Eligible Metropolitan Area Primary Care Clinic Infectious Disease Program CD4 cells or T-cells are the generals of the human immune system. These are the cells that send signals to activate your body s immune response when they detect intruders, like viruses or bacteria National HIV/AIDS Strategy Federal Poverty Level Rapid linkage program known as the Red Carpet Entry (RCE). The program facilitates rapid, efficient and effective linkage to HIV medical care the same day of testing positive or re-entry to care Jurisdictional HIV Prevention Plan Instructions 2 Ibid

12 Page11 INTRODUCTION This section describes the Atlanta-Sandy Springs-Marietta Metropolitan Area as a whole, including information about the HIV epidemic in Georgia

13 Page12 INTRODUCTION The Atlanta-Sandy Springs-Marietta Metropolitan Area (MSA) is a 28-county jurisdiction located in the north and northwest region of the state of Georgia. The Atlanta MSA counties are: Barrow, Bartow, Butts, Carroll, Cherokee, Clayton, Cobb, Coweta, Dawson, DeKalb, Douglas, Fayette, Forsyth, Fulton, Gwinnett, Haralson, Heard, Henry, Jasper, Lamar, Meriwether, Newton, Paulding, Pickens, Pike, Rockdale, and Spalding. Figure 1 highlights Georgia counties, major cities, and public health districts. Figure 1. Georgia Counties, major cities, and public health districts Georgia has 18 health districts which ranged in size from one to 16 counties based on the size of the population. The Fulton Health District (3-2), which has only a single county (Fulton) and contains the city of Atlanta, had the largest population with 949,599 persons in Other heavily populated districts included East Metro (3-4), Cobb/Douglas (3-1), LaGrange (4-0), DeKalb (3-5), Northwest (1-1), North (2-0), Coastal (9-1) and North Central (5-2), all with over half a million people. The South Central Health District (5-1) had the smallest population. 3 Georgia has 159 counties ranging in size in 2009 from 1,703 persons in Taliaferro to 949,559 in Fulton. The four most populous counties were those containing and/or surrounding the city of Atlanta. These were Fulton, DeKalb, Cobb, and Gwinnett counties. Together, their population made up one-third (33.6%) of Georgia s total population table. 4 3 Georgia Department of Public Health, HIV Epidemiology Unit, Surveillance Fact Sheet 4 Ibid

14 Page13 The HIV epidemic in Georgia is primarily driven by sexual exposure, especially among men who have sex with men and high-risk heterosexuals. Injecting drug use is also a high risk category, but less proportionate than through sexual contact. Communicable diseases pose a risk for HIV/AIDS transmission. According to the Centers for Disease Control and Prevention (CDC), Georgia had the 6 th highest number of cumulative AIDS cases in the United States through , and the 9 th highest rate of AIDS cases per 100,000 population as of December 31, The CDC estimated that 28,670 (range 20,008-37,332) adults and adolescents in Georgia were aware that they were infected with HIV (but did not have AIDS in that same year). In 2010, there were 795 newly- diagnosed HIV-Not AIDS cases and 512 AIDS cases in the Atlanta MSA. Of the HIV-Not AIDS cases, 24% occurred in individuals years of age, while individuals and years of age combined to make up 60% of the newly-diagnosed AIDS cases. Seventy- eight percent of the newly-diagnosed HIV-Not AIDS and AIDS cases in the Atlanta EMA were among Black, Non-Hispanic individuals. Within the Atlanta MSA, Fulton and DeKalb Counties had the highest 2010 HIV prevalence rates. 6 5 Centers for Disease Control and Prevention. Georgia-2010 Profile 6 HIV/AIDS Epidemiology Section, Division of Health Protection, Georgia Department of Public Health, Georgia HIV/AIDS Surveillance Summary, Data Through December 31,

15 Page14 OVERVIEW OF THE HIV/AIDS EPIDEMIC IN GEORGIA This section describes the current state of HIV/AIDS in Georgia.

16 Page15 OVERVIEW OF THE HIV/AIDS EPIDEMIC IN GEORGIA HIV/AIDS remains an important public health problem in Georgia. In 2009, Georgia had one of the highest rates of persons living with a diagnosis of HIV infection in the United States at 32.9 per 100,000 persons. The Atlanta MSA comprised more than 50% of the state population in 2010, and had the highest percentage of people living with HIV/AIDS in the state (66%). From 2001 to 2010, 71% of new HIV/AIDS diagnoses in Georgia occurred among males. Seventy-four percent of new HIV/AIDS diagnoses were among Black, non-hispanics. Among Black, non-hispanics, those in the age group of years had the highest rate of new HIV/AIDS diagnoses. The HIV/AIDS epidemic in Georgia is primarily driven by sexual exposure, especially among men who have sex with men and high-risk heterosexuals. Injection drug use is also a high risk category, but less prevalent than sexual contact. Communicable diseases like sexually transmitted infections (STI) and Tuberculosis (TB) pose a risk for individuals who are infected with HIV in Georgia. STDs can increase the risk for HIV infection from 2 to 5 times. For example, syphilis leads to decreased CD4 T-cell counts and increased plasma viral load in patients chronically infected with HIV, and this has been linked to increased HIV transmission. Equally important, TB is a leading cause of morbidity and mortality for people with HIV/AIDS. People who are co-infected with HIV and TB are at an increased risk of reactivation of latent TB and acquisition of new opportunistic infections. Transmission Category Definitions MSM refers to the transmission of HIV by male sexual contact with another male. IDU refers to transmission of HIV by receipt of non-prescribed drugs via injection, intravenously, intramuscularly, or subcutaneously. Perinatal refers to transmission of HIV from mother-to-child. Blood recipient refers to transmission of HIV through blood or blood components. HRH refers to transmission of HIV through heterosexual contact with a person known to have HIV infection or at least with a person at increased risk of HIV infection (based on a history of MSM, IDU, or receipt of blood products). NIR refers to HIV cases in which an HIV risk factor cannot be identified or confirmed even though (1) all available data sources have been reviewed or contacted or (2) epidemiological follow-up was either not initiated or not completed, but 12 months have elapsed since the date of the initial case report. NRR refers to HIV cases that were reported without any risk factor information. Newly Diagnosed HIV/AIDS Cases in Georgia Counties There were 1,294 newly-diagnosed HIV-Not AIDS cases in Georgia in Of these cases, 260 (20%) occurred in Fulton County. DeKalb County also had a high number of new HIV-Not AIDS cases. DeKalb had 258 HIV- Not AIDS cases in 2010, which was 20% of the state s total. Clayton County had the third highest number of new HIV-Not AIDS cases in 2010 with 90 cases, or 7% of the state s total cases. Fulton (164 cases), DeKalb (160 cases), and Clayton (90 cases) counties combined to comprise 52% of the state s new AIDS diagnoses in (Table 1) 7 7 Integrated Epidemiologic Profile of HIV/AIDS, Georgia, 2011 Department of Public Health Division of Health Protection Epidemiology Program HIV/AIDS Epidemiology Section

17 Page16 Table 1: Newly Diagnosed HIV (not AIDS) and AIDS by Gender, Age and Race/Ethnicity, Georgia from January 1, December 31, 2010 HIV (not AIDS) AIDS Total Gender Count Percent Count Percent Count Percent Male , Female Age at Diagnosis (years) Count Percent Count Percent Count Percent <13 4 < < Race/Ethnicity Count Percent Count Percent Count Percent White, Non-Hispanic Black, Non-Hispanic 1, , Hispanic/Latino, Any Race American Indian/Alaskan Native, Non-Hispanic 1 < <1 Asian/ Hawaiian/Pacific Islander, Non-Hispanic 9 < <1 Multiracial/Unknown/Others, Non-Hispanic 6 <1 3 <1 9 <1 Male Transmission Category Count Percent Count Percent Count Percent MSM IDU 7 < MSM and IDU 3 < Blood recipient HRH Perinatal 1 <1 1 <1 2 <1 NIR/NRR Subtotal ,527 Female Transmission Category Count Percent Count Percent Count Percent IDU 3 < Blood recipient HRH Perinatal NIR/NRR Subtotal Total Persons Living with HIV/AIDS in Atlanta EMA There were 27,560 individuals living with HIV-Not AIDS or AIDS in the Atlanta Metropolitan Statistical Area (MSA) as of December 31, Of these individuals, 78% were male. Thirty-two percent of the individuals living with HIV-Not AIDS as of December 31, 2010, in the Atlanta EMA were years old. Twenty percent of the cases in the Atlanta MSA as of December 31, 2010 occurred in females. Of these females, 26% occurred in high-risk heterosexual (HRH). Sixty-eight percent of persons living with AIDS in the Atlanta MSA as of December 31, 2010 were Black, Non-Hispanic, and 59% of persons living with AIDS were MSM. 8 Persons Living with HIV/AIDS in Georgia Counties Fulton County had the highest number of persons living with HIV-NA or AIDS as of December 31, 2010 with 11,740. Second to Fulton County was DeKalb County with 7,634. Clayton County had the third highest number of persons living with HIV-Not AIDS or AIDS as of December 31, 2010 with 1,952. (Table 2) 8 Integrated Epidemiologic Profile of HIV/AIDS, Georgia, 2011 Department of Public Health Division of Health Protection Epidemiology Program HIV/AIDS Epidemiology Section

18 Page17 Table 2: Persons Living with HIV (not AIDS) and AIDS by Current Public Health District of Residence, Georgia, 2010 HIV (not AIDS) 1 AIDS 2 Total Public Health District Count 3 Rate 4 Count Rate Count Rate 1-1 Northwest (Rome) North Georgia (Dalton) North (Gainesville) Cobb-Douglas 1, , , Fulton 4, , , Clayton (Jonesboro) , , East Metro (Lawrenceville) , , DeKalb 3, , , La Grange , South Central (Dublin) North Central (Macon) , East Central (Augusta) , , West Central (Columbus) , South (Valdosta) Southwest (Albany) , Coastal (Savannah) , , Southeast (Waycross) Northeast (Athens) GA Cases with Unknown Health District Total 18, , , Note: Case counts include incarcerated persons and may inflate rates in certain geographic regions where there are large concentrations of HIV-positive inmates. 1 Persons Living with HIV (not AIDS) refers to persons living with HIV (not AIDS) as of December 31, 2010, who were currently residing in Georgia regardless of their state of residence at the time of HIV (not AIDS) diagnosis. Persons are assumed to be alive unless otherwise documented or reported. 2 Persons Living with AIDS refers to persons living with AIDS as of December 31, 2010, who were currently residing in Georgia regardless of their state of residence at the time of AIDS diagnosis. Persons are assumed to be alive unless otherwise documented or reported. 3 Numbers are based on data entered through June 30, 2011, and are not adjusted for reporting delays. 4 Rates are calculated as the number of cases per 100,000 population and are based on Georgia 2010 population estimates obtained from the 2010 U.S. Census. HIV and STI Co-infections Sexually transmitted infections (STI) co-infection (gonorrhea, chlamydia, or syphilis) in persons with HIV/ AIDS in Georgia in 2010 overwhelmingly occurred among males (82%). People years of age had the highest percentage of co- infections with 63% of the total. Black, Non-Hispanics had the highest percentage of co-infection of all races/ethnicities, with 79% of cases. White, Non-Hispanics were a distant second with 16%. In terms of HIV transmission category for males with HIV and STI co-infection, MSM were the highest with 64% of cases; no identified risk (NIR)/no reported risk (NRR) was second with 27%. For co-infected females, 23% reported HRH transmission and 10% reported intravenous drug use (IDU) transmission. The majority of HIV and STD co-infected females reported NIR/NRR transmission (66%). (Table 3) 9 9 Integrated Epidemiologic Profile of HIV/AIDS, Georgia, 2011 Department of Public Health Division of Health Protection Epidemiology Program HIV/AIDS Epidemiology Section

19 Page18 Table 3: Persons Living with HIV/AIDS Who Were Ever Co-Infected with a New Reportable STD by Gender, Age, Race/Ethnicity, Georgia as of December 31, 2010 HIV (not AIDS) AIDS Total Gender Count Percent Count Percent Count Percent Male Female Age at Diagnosis (yr.) Count Percent Count Percent Count Percent < < Race/Ethnicity Count Percent Count Percent Count Percent White, Non-Hispanic Black, Non-Hispanic Hispanic/Latino, Any Race American Indian/Alaskan Native, Non-Hispanic 4 <1 6 <1 10 <1 Asian/ Hawaiian/Pacific Islander, Non-Hispanic 10 <1 6 <1 16 <1 Multiracial/Unknown/Others, Non-Hispanic Male Transmission Category Count Percent Count Percent Count Percent MSM IDU MSM and IDU Blood recipient <1 2 <1 HRH Perinatal 1 <1 1 <1 2 <1 NIR/NRR Subtotal Female Transmission Category Count Percent Count Percent Count Percent IDU Blood recipient HRH Perinatal 4 <1 3 <1 7 <1 NIR/NRR Subtotal Total HIV and Tuberculosis (TB) Co-infection in Georgia There were 27 persons newly diagnosed with HIV/AIDS and TB co-infections in Georgia in Nearly 75% of these new cases were among males. The majority of newly diagnosed cases with HIV and TB coinfection were Black, Non-Hispanics (67%). Hispanic/Latinos, Any Race had the second highest number of co-infected cases with 19%. White, Non-Hispanics and Asian/Hawaiian/Pacific Islander, Non-Hispanics had an equal percentage of cases with 7% each. Persons years of age had the highest percentage of reported TB co- infection with 33%; people years of age had the second-highest percentage with 26%, and people years of age had the third-highest percentage with 19%. (Table 4) Integrated Epidemiologic Profile of HIV/AIDS, Georgia, 2011 Department of Public Health Division of Health Protection Epidemiology Program HIV/AIDS Epidemiology Section

20 Page19 Table 4: Newly Diagnosed HIV/AIDS and TB Co-infections, Georgia from January 1, December 31, 2010 HIV/AIDS Gender Count Percent Male Female 7 26 Age at Diagnosis (year) Count Percent < Race/Ethnicity Count Percent White, Non-Hispanic 2 7 Black, Non-Hispanic Hispanic/Latino, Any Race 5 19 American Indian/Alaskan Native, Non-Hispanic 0 0 Asian/ Hawaiian/Pacific Islander, Non-Hispanic 2 7 Multiracial/Unknown/Others, Non-Hispanic 0 0 Total

21 Page20 EPIDEMIOLOGY OF HIV/AIDS IN FULTON/DEKALB COUNTIES This section describes an overview of HIV/AIDS in Fulton and DeKalb Counties. It provides an overview of the number of newly diagnosed AIDS cases, HIV rates in 2010.

22 Page21 EPIDEMIOLOGY OF HIV/AIDS IN FULTON/DEKALB COUNTIES As of 2010, the total population of Fulton County is 920,581 (9.5% of Georgia population) and 691,893 for DeKalb County (7.1% of Georgia population) (Table 5). 11 Table 5. Distribution of the General Population, by Race/Ethnicity and Health District, Georgia, 2010 County Total population Fulton 920,581 (9.5) DeKalb 691,893 (7.1) Georgia 8,075,179 (83.4) Total 9,687,653 (100.0) White, Non- Hispanic 376,014 (6.9) 203,395 (3.8) 4,834,511 (89.3) 5,413,920 (55.9) Black, Non- Hispanic 400,457 (13.8) 370,963 (12.7) 2,139,380 (73.5) 2,910,800 (30.0) Hispanic 72,566 (8.5) 67,824 (7.9) 713,299 (83.6) 853,689 (8.8) Asian/HA /PI 51,591 (16.3) 35,418 (11.2) 229,835 (72.5) 316,844 (3.3) American Indian /Alaskan 1,586 (9.7) 1,239 (7.6) 13,454 (82.6) 16,279 (0.2) Multiracial Unknown Other 18,367 (10.7) 13,054 (7.6) 139,791 (81.6) 171,212 (1.8) A. Newly Diagnosed HIV (Not AIDS) and AIDS Cases From January 1, 2010 to December 31, 2010, there were 776 (60.0%) persons newly diagnosed with HIV (not AIDS) 12 and 419 (56.4%) persons newly diagnosed with AIDS in Georgia 13 ; 260 (20.1%) and 164 (22.1%) in Fulton County; and 258 (19.9%) and 160 (21.5%) in DeKalb County respectively (Table 6). Table 6. Newly Diagnosed HIV (Not AIDS) and Cases in Fulton and DeKalb Counties as compared to Georgia, 2010 Area HIV (not AIDS) (N=1,294) AIDS (N=743) Total (N=2037) Fulton 260 (20.1%) 164 (22.1%) 424 (20.8%) DeKalb 258 (19.9%) 160 (21.5%) 418 (20.5%) Georgia 776 (60.0%) 419 (56.4%) 1195 (58.7%) In both Counties, the majority of individuals newly diagnosed with HIV (Not AIDS) cases were male (Fulton 82%, DeKalb 79%, GA 71%), and Black/Non-Hispanics (Fulton 84%, DeKalb, 79%, GA 75%) who accounted for the majority of newly diagnosed HIV (Not AIDS) cases among all races/ethnicities (Table 7). 11 Integrated Epidemiologic Profile of HIV/AIDS, Georgia, 2011 Department of Public Health Division of Health Protection Epidemiology Program HIV/AIDS Epidemiology Section 12 Includes HIV and/or AIDS 13 Excludes cases in Fulton and DeKalb Counties

23 Page22 Table 7. Newly Diagnosed HIV (Not AIDS) Cases by Sex and Race in Georgia, 2010 Fulton DeKalb GA HIV(not AIDS) (N=260) AIDS (N=164) Total (N=424) HIV(not AIDS) (N=258) AIDS (N=160) Total (N=418) HIV (not AIDS) (N=776) AIDS (N=419) Total (N=1195) Sex Male 212(82) 130(79) 342(81) 205(79) 131(82) 336(80) 545(70) 304(73) 849(71) Female 48(19) 34(21) 82(19) 53(21) 29(18) 82(20) 231(30) 115(27) 346(29) Race White 26(10) 19(12) 45(11) 35(14) 17(11) 52(12) 157(20) 71(17) 228(19) Black 219(84) 135(82) 354(83) 206(80) 125(78) 331(79) 583(75) 318(76) 901(75) Hispanic 13( 5) 10( 6) 23( 5) 10( 4) 15( 9) 25( 6) 29( 4) 22( 5) 51( 4) Other 2( 1) 0( 0) 2( 1) 7( 3) 3( 2) 10( 2) 7( 1) 8( 2) 15( 1) When compared to the percentage of individuals newly diagnosed with HIV (not AIDS) by age group, Fulton and DeKalb Counties show somewhat different results. Individuals years of age (24.6%) were the majority of cases in Fulton County, followed by (21.5%), (18.5%) and (17.3%), while individuals (28.3%) years of age were the majority of cases in DeKalb County, followed by (19.4%), (17.4), and (17.1%). Overall, persons who were newly diagnosed with HIV (Not AIDS) in Fulton County were, on average, younger than those who were newly diagnosed in DeKalb County (Figure 2). 14 Figure 2. Percentage of individuals newly diagnosed with HIV (not AIDS) in Fulton and DeKalb Counties compared to Georgia by age group, Fulton DeKalb GA < Integrated Epidemiologic Profile of HIV/AIDS, Georgia, 2011 Department of Public Health Division of Health Protection Epidemiology Program HIV/AIDS Epidemiology Section

24 Page23 Male-to-male sexual contact was the most frequently reported transmission category for males while the majority of female cases were missing risk information or did not meet one of the CDC-defined transmission categories. Of the Individuals newly diagnosed with HIV disease by transmission category in Fulton County, 65% reported no risk or no identified risk (NRR/NIR), 33% men who have sex with men (MSM), 1.2% high risk heterosexual sex (HRH), 1% injection drug user (IDU); 66% NRR/NIR, 33% MSM, and 1% IDU for DeKalb County as compared to 66% NRR/NIR; 26% MSM; 7% HRH and 1% IDU; for Georgia (Figure 3). Figure 3. Percentage of individuals Newly Diagnosed with HIV (not AIDS) in Fulton and DeKalb Counties compared to Georgia by Transmission Category, Fulton DeKalb GA MSM IDU MSM/IDU Blood recipient HRH Perinatal NIR/NRR MSM = MEN WHO HAVE SEX WITH MEN; IDU = INJECTION DRUG USER; HRH = HIGH-RISK HETEROSEXUAL SEX NRR = NO REPORTED RISK; NIR = NO IDENTIFIED RISK B. Persons Living with HIV (Not AIDS) and AIDS From January 1, 2010 to December 31, 2010, there were 22,612 persons (54%) living with HIV Disease in Georgia, 11,740 (28%) percent in Fulton County and 7,634 (18%) in DeKalb County (Table 8). Table 8. Persons living with HIV (Not AIDS) and AIDS in Fulton and DeKalb Counties as compared to Georgia, 2010 Area HIV (not AIDS) (N=18,535) AIDS (N=23,451) Total (N=41,986) Fulton 4,387 (23.7%) 7,353 (31.4%) 11,740 (28.0%) DeKalb 3,530 (19.0%) 4,104 (17.5%) 7,634 (18.2%) Georgia 10,618 (57.3%) 11,994 (51.1%) 22,612 (53.9%)

25 Page24 Overall, the majority of individuals living with HIV (Not AIDS) and AIDS were male (15,550, 68.8%), and Black/Non-Hispanics (15,562, 68.8%) who accounted for the majority of persons living with HIV (Not AIDS) and AIDS among all races/ethnicities in Georgia; 9,525(81.1%) and 8,551(72.8%) in Fulton; 6,070(79.5%) and 5,357(70.2%) in DeKalb respectively (Table 9). Table 9. Persons living with HIV (Not AIDS) and AIDS Cases by sex and race in Georgia in 2010 HIV(not AIDS) N=4,387 Sex Male 3,441 (78.4) Female 946 (21.6) Race White 879 (20.0) Black 3,262 (74.4) Hispanic 153 (3.5) Other 93 (2.1) Fulton DeKalb GA AIDS Total AIDS Total N=7,353 N=11,740 N=4,104 N=7,634 6,084 (82.7) 1,269 (17.3) 1,659 (22.6) 5,289 (71.9) 253 (3.4) 152 (2.1) 9,525 (81.1) 2,215 (18.9) 2,538 (21.6) 8,551 (72.8) 406 (3.5) 245 (2.1) HIV(not AIDS) N=3,530 2,725 (77.2) 805 (22.8) 838 (23.7) 2,449 (69.4) 154 (4.4) 89 (2.5) 3,345 (81.5) 759 (18.5) 919 (22.4) 2,908 (70.9) 201 (4.9) 76 (1.9) 6,070 (79.5) 1,564 (20.5) 1,757 (23.0) 5,357 (70.2) 355 (4.7) 165 (2.2) HIV(not AIDS) N=10,618 6,972 (65.7) 3,646 (34.3) 2,426 (22.8) 7,542 (71.0) 472 (4.4) 178 (1.7) AIDS N=11,994 8,578 (71.5) 3,416 (28.5) 3,098 (25.8) 8,020 (66.9) 656 (5.5) 220 (1.8) Total N=22,612 15,550 (68.8) (31.2) 5,524 (24.4) 15,562 (68.8) 1,128 (5.0) 398 (1.8) When compared, the percentage of persons living with HIV (not AIDS) by age group, the age group of (31%, 31.2%, 32.6%) was the majority of cases in Georgia, Fulton County and DeKalb County respectively followed by (23.9%, 26.2%, 26.8%), (18.3%, 18.5%, 17%) and (10.7%,11.3%, 11.2%) (Figure 4). Figure 4. Percentage of individuals living with HIV (not AIDS) as of December 31, 2010 in Fulton and DeKalb Counties compared to Georgia by age group < Fulton DeKalb GA

26 Page25 Male-to-male sexual contact was the most frequently reported transmission category for males. Of the persons living with HIV (Not AIDS) by transmission category, 39.7% reported no risk or no identified risk (NRR/NIR), 44.8% men who have sex with men (MSM), 5.5% high risk heterosexual sex (HRH), 4.9% injection drug user (IDU) in Fulton County; 41.8% NRR/NIR, 47.8% MSM, 3% IDU; and 4.5% HRH for DeKalb County as compared to 51.6% NRR/NIR; 28.8% MSM; 4.6% IDU; and 11.8% HRH for Georgia (Figure 5). Figure 5. Percentage of individuals living with HIV (not AIDS) in Fulton and DeKalb Counties compared to Georgia by Transmission Category, MSM IDU MSM/IDU Blood recipient HRH Perinatal NIR/NRR Fulton DeKalb GA

27 Page26 HIV PREVENTION, LINKAGE TO CARE, AND TREATMENT SERVICES IN THE JURISDICTION This section describes the available HIV Testing sites in Fulton and DeKalb Counties, resources allocated to address linkage to care and treatment services, and estimated level of services gaps among persons living with HIV/AIDS.

28 Page27 HIV PREVENTION, LINKAGE TO CARE, AND TREATMENT SERVICES IN THE JURISDICTION SERVICES A. Existing HIV Prevention Resources and Services The Centers for Disease Control and Prevention (CDC) announced a 5-year HIV prevention funding opportunity for health departments in states, territories, and select cities. CDC s new funding opportunity represents a new direction in HIV prevention, and is designed to achieve a higher level of impact with every federal HIV prevention dollar. The purpose of this Funding Opportunity Announcement (FOA) is to support implementation of high impact, comprehensive HIV prevention programs to achieve maximum impact on reducing new HIV infections. In accordance with the National HIV/AIDS Strategy (NHAS), this FOA focuses on addressing the national HIV epidemic, reducing new infections, increasing access to care, improving health outcomes for people living with HIV, and promoting health equity. The aforementioned will be achieved by enhancing public health departments capacities to increase HIV testing, refer and link HIV positive persons to medical care and other essential services, and increase program monitoring and accountability. 15 The goal of this Funding Opportunity Announcement (FOA) is to reduce HIV transmission by building capacity of health departments to: focus HIV prevention efforts in communities and local areas where HIV is most heavily concentrated to achieve the greatest impact in decreasing the risks of acquiring HIV; increase HIV testing; increase access to care and improve health outcomes for people living with HIV by linking them to continuous and coordinated quality care and much needed medical, prevention and social services; increase awareness and educate communities about the threat of HIV and how to prevent it; expand targeted efforts to prevent HIV infection using a combination of effective, evidencebased approaches, including delivery of integrated and coordinated biomedical, behavioral, and structural HIV prevention interventions; and reduce HIV-related disparities and promote health equity. The Centers for Disease Control and Prevention funds for a cooperative agreement program for health departments to develop and implement comprehensive HIV prevention programs in the following three categories: Category A: HIV Prevention Programs for Health Departments; Category B: Expanded HIV Testing for Disproportionately Affected Populations; and Category C: Demonstration Projects to Implement and Evaluate Innovative, High Impact HIV Prevention Interventions and Strategies. 16 Fulton County Department of Health and Wellness (FCDHW) applied for funding under Categories A and B to support a variety of HIV testing and prevention efforts in Fulton and DeKalb Counties in Georgia. Fulton and DeKalb have the highest percentage of Persons Living with HIV in the Atlanta Metropolitan Statistical Area with 43.8% and 27.1% respectively. The epidemic in Atlanta: disproportionately affects African Americans; is overwhelmingly male; and, has most impacted MSM. The target populations are African American Men who have Sex with Men (MSM), MSM, and high-risk heterosexuals. FCDHW also proposed an innovative demonstration project under Category C, focus area (2) innovative testing activities that increase identification of undiagnosed HIV infections and/or improve the cost effectiveness of HIV testing activities. CATEGORY A. Annual goals of FCDHW Comprehensive HIV Prevention Program are to: 1) increase HIV testing and opt-out testing; 2) increase the proportion of HIV-infected people who know they are 15 PS CDC Funding Opportunity Announcement Guidance for Comprehensive HIV Prevention for Health Departments 16 Ibid

29 Page28 infected; 3) increase the proportion of HIV-infected persons who are linked to prevention and care services; 4) increase awareness and educate communities about HIV and how to prevent it; 5) expand targeted efforts to prevent HIV infection using a combination of effective evidenced-based approaches; 6) reduce HIV related disparities and promote health equity; 7) provide behavioral risk screening followed by individual and group-level evidenced-based interventions for HIV-negative persons at highest risk for HIV; and 8) develop a social media communication strategy using guidelines in CDC s Social Media Toolkit. Prevention efforts will be supported by an HIV prevention planning process to include the development of a jurisdictional HIV prevention plan and establishment of an HIV prevention planning group. FCDHW and the planning group will partner with prevention training centers to conduct a capacity-building needs assessment, and to monitor the HIV/AIDS epidemic within the jurisdiction for program planning, resource allocation and evaluation purposes. 17 CATEGORY B. FCDHW will provide expanded HIV testing for disproportionately affected populations in an effective and efficient client-centered HIV prevention program. CATEGORY C. Project Enhanced Detection to Decrease HIV Infections (Project EDDI) The Use of Nucleic Acid Amplification Testing (NAAT) or Fourth Generation Testing in the Early Identification of HIV in Persons with Sexually Transmitted Infections (STIs) as a Means of Reducing HIV Transmission. This project will incorporate testing for acute HIV infection in persons from areas of high HIV prevalence who seeks STIs services because it has been shown that concurrent STI increases the susceptibility and transmissibility of HIV. FCDHW seeks to augment the existing HIV screening algorithm with enhanced testing to identify and treat highly-infective persons with acute HIV who would otherwise not be detected due to the window period of standard HIV testing, followed by partner notification and directed community outreach to prevent other new infections in high prevalence areas. FCDHW will implement new specimen pooling strategies to reduce the cost of NAAT without compromising capacity to detect acute HIV infection. The Centers for Disease Control and Prevention allocated $4,981, dollars to support the HIV prevention efforts of Fulton County and neighboring DeKalb County. The funding breakdown is as follows for Category A and B. Category C funding of $467,317 is for a demonstration project at Fulton County Department of Health and Wellness. (Figure 6) 17 PS CDC Funding Opportunity Announcement Guidance for Comprehensive HIV Prevention for Health Departments

30 Page29 Figure 6. The Centers for Disease Control and Prevention allocated $4,981, dollars to support the HIV prevention efforts of Fulton County and DeKalb Counties Category A and B FY12 Funding Allocation 2,340, ,485, , ,320 73,839 Indirect Contracts Supplies Admin Other The Centers for Disease Control and Prevention and the Substance Abuse and Mental Health Services Administration (SAMHSA) have allocated approximately $10.5 million dollars to support the HIV prevention efforts of Georgia s community-based organizations, AIDS service organizations, county health departments, and the Georgia Department of Public Health. 18 B. Linkage to Care and Treatment Services at Fulton Ryan White Part A Program for the Atlanta EMA - $1,500,000 Fulton County Government administers the Ryan White Part A program for the Atlanta Metropolitan Statistical Area (MSA) and is tasked with improving access to care and treatment for people who are HIV positive, but not in care. Efforts are in process to increase the number of people in care and treatment who have not been tested for HIV, but are HIV-positive, as well as those who know they are living with HIV, but are not in care. Fulton County Department of Health and Wellness (FCDHW) Communicable Disease Prevention Branch (CDPB) is a key partner in the EMA s linkage to care efforts. Furthermore, as the service provider for the largest number of persons living with HIV not-aids in the MSA, as well as the largest provider of HIV screenings in the MSA, FCDHW is positioned to play a key role in bridging medically underserved HIV positive individuals to care and treatment services. CDPB, in concert with the Primary Care Clinic (PCC) will provide primary care services to individuals who are HIV-positive, and to ensure that individuals receive the best preventive service and treatment possible whenever they interact with the PCC providers. The FCDHW/CDPB primary care services include the provision of 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, care of minor injuries, education and counseling on health and nutritional issues, 18 Jurisdictional HIV Prevention Plan Update , State of Georgia, page 27.

31 Page30 continuing care and management of chronic conditions, and referral to and provision of specialty care. Primary medical care for the treatment of HIV infection includes the provision of care consistent with US Public Health Service Guidelines (USPHS). Care includes access to antiretroviral and other drug therapies, including prophylaxis and treatment of opportunistic infections and combination antiretroviral therapies. PCC provides substance abuse assessments and individual/group counseling for clients identified as needing further substance abuse evaluation. Referrals are provided to clients needing detoxification and long-term treatment. To improve access and retention in primary care, PCC provides food assistance and medical transportation. The PCC staff provides referrals that are consistent with HIPAA, USPHS, and FCDHW confidentiality guidelines. The PCC will work with Linkage Coordinators to initiate referrals and provides follow-up with clients to determine if they: 1) kept their primary care medical appointment; 2) did they received the requested services, and 3) were there services provided in an appropriate and professional manner as rated on the Client Satisfaction Survey. Follow-up with a client includes face-toface or telephone contact with the client. This also means that the PCC staff or Linkage/Retention Coordinator (LRC) will accompany the client to his/her schedule appointment. Merck Company Foundation HIV Care Collaborative $333,333 ($999, for 3 years) Fulton County Department of Health and Wellness Bridging the Gap Program focuses on HIV-positive persons referred to and enrolled in the county s HIV Primary Care clinic by implementing a communitybased Linkage Coordinator and referral program. The role of the Linkage Coordinators will assist in enrolling clients into PCC. They will also assist newly diagnosed clients in navigating the system (PCC); work with the case managers to link newly diagnosed and previously HIV-positive clients to needed external resources; and making appointment reminder calls. Test, Link and Care Program - $137,900 Test, Link and Care Program is to ensure that newly identified HIV-positive persons and individuals lost to care are linked to medical care and prevention services. Through the use of a brief case management, strengths-based care, Linkage Coordination and a systematic networking among HIV care providers, this program aim to identify and promptly link to care persons who are living with HIV but not receiving treatment. Ryan White Part B Minority AIDS Initiative $67,839 Ryan White Part B Minority AIDS Initiative is to implement a linkage to care model that will identify and promptly link individuals living with HIV not receiving treatment. Enhanced Comprehensive HIV Prevention Plan -$100,000 Enhanced Comprehensive HIV Prevention Plan is to provide partner services in clinical and non-clinical settings to clients who test positive for HIV, and linking HIV-positive persons to care and treatment. C. Existing HIV Prevention Interventions Currently, there are more than 14 individual and group-level evidenced-based interventions (EBI) offered in the state of Georgia. The individual and group-level EBIs offered in Fulton and DeKalb Counties are highlighted in Attachment B.

32 Page31 D. Needs and Gaps in HIV Prevention Estimated level of service gaps among Persons Living with HIV/AIDS (PLWHA) in the MSA: Service gaps were documented in a number of specific needs assessments/consumer surveys carried out by the Metropolitan Atlanta HIV Health Services Planning Council in the MSA during the past few years. Using data from the HIV/AIDS reporting system (ehars), the statewide laboratory database and the Georgia Department of Public Health, HIV Epidemiology Unit, it has been estimated that 56% of PLWHA in the MSA had not received primary health care services during Apart from primary health care, there are also two other areas in which there are gaps in services. Data from the 2008 Atlanta MSA HIV Consumer Survey and the CAREWare database indicate 39% of PLWHA have mental health problems, specifically depression, but only 21% of clients at Part A funded service sites received mental health services during There are 10,485 persons with mental health needs. 20 Data from the same sources indicate that 9% of PLWHA in the MSA (2,420) have substance abuse problems as a contributing factor in their infection and will need additional care. The 2008 Consumer Survey conducted by the Southeast AIDS Education and Training Center (SEATEC) sought data concerning services accessed by PLWHA at 12 Part A and 8 non-part A funded local AIDS service organizations (the consumer survey performed in 2011 is still being analyzed). The four services most needed and not received were Oral Health Care, Food Pantry, Home Delivered Meals and Legal Services. For Hispanics, Support Groups and Counseling was high in the most needed and not received service, and for Whites, Legal Help was also in the top five services needed but not received. 21 Of the 26 services examined in 2008, eight services were in high need by at least 15% of all respondents. Hispanics and females aged between 18 and 44 years reported the greatest number of services in high need (n=8), followed by African Americans, females and males in general (n=7) and Whites (n=5). Females and males were similar in their reported service use, service needs, and number of services in high need. 22 In addition, in the 2008 Consumer Survey, people living with HIV for less than three years perceived a greater need for oral health care, referrals to services, emergency help paying utility bills, mental health counseling, 1:1 peer counseling, and support groups. People living with HIV for more than 11 years were more likely to use other HIV medications, oral health care, support groups, and drug/alcohol counseling. 23 Lastly, respondents indicated that if they had a case manager, they were more likely to use services and report fewer services needed but not received. While 70% of participants reported having a case manager, Hispanics were less likely than African American and White clients to have accessed this service. Hispanics also identified more barriers overall to receiving specific services that were needed but not received, such as oral health care, help paying utility bills or buying groceries, or obtaining free groceries. Participants who were diagnosed HIV positive for three years were more likely to identify Atlanta EMA Ryan White Grant Application to HRSA, page 5 20 Ibid 21 Ibid 22 Ibid 23 Ibid

33 Page32 personal and information barriers, whereas those who were HIV positive for more than 11 years were less likely to report capacity and information barriers. Participants with lower functional health literacy were more likely to report financial, system, and information barriers. 24 (Table 10) Table 10. Assessment of Emerging Population with Special Need and Unique Gaps in Services Emerging Populations Young Men who Have Sex with Men (15-30 years of age) 25 Women of Childbearing Age(15-49) Hispanics Aging PLWHA, 50 Years of Age and Older Services Service gaps include insufficient outreach initiatives that create awareness and educate MSM about HIV/AIDS and safer sex practices, social support groups that address substance abuse and mental health issues and the stigma associated with the complexity of multiple health problems. Other gaps in services identified through the HIV Consumer Survey include primary prevention services for oral health, transportation, and emergency assistance for paying household utilities. Services including outpatient ambulatory care, oral health care, mental health counseling, and family case management are needed for adult and adolescent women. These services, along with on-site childcare and a Pediatric Care Unit, are provided comprehensively solely at the Grady Infectious Disease Program (IDP). The centralized case management system facilitates referrals to other programs such as housing, financial and food assistance programs. Through the Ryan White Part D program, Grady Hospital s Obstetrics (OB) program has resources in place to provide prenatal care to uninsured HIV positive pregnant women. The 2008 HIV Consumer Survey reports a high rate of primary care usage (80%) among women, yet only 69% use antiretroviral medications. The top services needed but not received were: oral health care, food, transportation assistance, home-delivered meals, and referrals to services. There are existing gaps in the provision of needed services in the general population and the limited number of culturally appropriate services for Hispanic clients increases these gaps multiple times. In the MSA there are a limited number of infectious disease specialists, almost none whom are culturally aligned with the Hispanic population. In addition, many people of Hispanic origin have culturally directed treatment concepts that are not recognized by the traditional Caucasian specialist. This includes use of alternative treatments and therapies (acupuncture, vitamins, bio-identical drugs to name a few). All hospitals do provide translators which often fall short of cultural sensitivity. There will be two major effects of the aging population on the medical system. The first is that the resources required to manage these chronic diseases in PLWHA are limited. In the MSA the infectious disease specialists currently managing the HIV component of their disease cannot manage all the other chronic disease aspects. Other specialists who serve low income individuals are already over worked. The second is the sheer fiscal cost of managing these aging PLWHA. Service needs, gaps and barriers to care: From the results of the unmet need analysis, it is clear that getting individuals into HIV primary care must be a continuing priority. In the 2008 Consumer Survey, consumers reported using medical and information services at high rates in the past 30 days (primary medical care 77% and antiretroviral medications 73%). Dental care (46%) was the most frequently reported service needed but not received. The most commonly reported barriers for consumers were personal (26%), followed by information (19%) and capacity (16%). Additional analysis revealed that capacity (20%) and other barriers (20%) were reported by consumers earning an annual income less than 100% of Federal Poverty Level (FPL). Information barriers were reported more frequently by Hispanics (33%), women (31%), and especially women of childbearing age (37%). Personal barriers, the most commonly reported of all, indicated the highest statistically significant rates for men (28%). Participants were asked screening questions regarding substance abuse and mental health. Of the 313 participants that completed the 24 Ibid, page Atlanta EMA Ryan White Grant Application to HRSA, pages 23-34

34 Page33 screening, 80 (26%) consumers were in need of additional substance abuse assessment and 136 (39%) were in need of additional mental health assessment. 26 Gaps in HIV prevention services Gaps in HIV prevention services were based on the two-day community engagement forum. Some of the strategies and recommendations are as follows: Identifying point of entry sites to develop a network of service providers offering HIV testing Strategic social media messaging for HIV prevention services Peer navigators to link HIV infected clients to care services Routine HIV testing offered across populations and locations On-site confirmatory HIV testing Multi-lingual service options and culturally competent services for all clients Culturally competent services for all clients Community forum participants identified specific challenges and needs, including environmental barriers that include: Routine HIV testing in healthcare settings Additional time allotted with physicians during appointments Integrated community education about value of testing for HIV and other STIs Health literacy of client Client adherence to HIV treatment Lack of services for transgender population Medicaid restrictions, other treatment funding challenges Lack of patient navigators to guide clients through healthcare system At-risk individuals require more tailored prevention education Knowledge of healthcare providers regarding HIV/AIDS and HIV/AIDS treatment Additionally, gaps in HIV services identified in the 2011 Georgia of Public Health Enhanced Comprehensive HIV Prevention Plan (ECHPP) are as follows: Lack of established guidelines for directing resources to areas with high morbidity in the MSA. 27 Reach: Lack of guidelines to follow on how interventions are selected for MSA and statewide use. 28 Coordination: Although testing is often provided at locations requested by community groups or organizations, these efforts have been limited by a lack of monitoring, tracking and evaluation, and comprehensive, standardized and sustained HIV training and technical assistance. 29 Services: Opt-out testing in clinical settings (public and private) is not being conducted by all service providers due to capacity and comfort levels. Although, the Official Code of Georgia Annotated supports testing pregnant women for HIV, many providers are unaware of this regulation and do not routinely offer prenatal HIV testing. Furthermore, high risk individuals with comorbidities (i.e., other STDs, viral hepatitis, and/or tuberculosis) are not consistently being offered optout testing in clinical settings Ibid 27 Georgia of Public Health Enhanced Comprehensive HIV Prevention Plan (ECHPP) 28 ECHPP 29 Ibid 30 Ibid

35 Page34 PROCESS FOR DEVELOPING THE CITY OF ATLANTA (FULTON/DEKALB COUNTIES) JURISDICTION HIV PREVENTION PLAN The section describes the step-by-step process of the development of the City of Atlanta (Fulton/DeKalb Counties) Jurisdictional HIV Prevention Plan. It highlights information on a series of meetings that were convened to engage community stakeholders in the identification and prioritization of innovative HIV prevention strategies to address the high burden of HIV. This section also describes how the planning, development and implementation process will be monitored.

36 Page35 PROCESS FOR DEVELOPING THE JURISDICTION HIV PREVENTION PLAN Vision When every person in Fulton and DeKalb Counties is empowered to know their HIV status, and if HIVpositive, choose to access high quality care and treatment Mission To achieve optimal HIV prevention and care services, by mobilizing partnerships and taking strategic action Guiding Principles The development of the City of Atlanta (Fulton/DeKalb Counties) Jurisdictional HIV Prevention Plan 2012-, is guided by seven principles. These principles ensure the plan and planning process would: 1. Promote an appreciation for the dynamic interrelationships of all components local health system required to develop a vision of a healthy community. 2. Ensure respect for diverse voices and perspectives during the collaborative process. 3. Form the foundation for building a shared vision around HIV prevention. 4. Provide factual information during each step of the process. 5. Optimize performance and services through shared resources and responsibility. 6. Foster a proactive response to the issues and opportunities facing the system. 7. Ensure that contributions are recognized and sustain excitement for the process. The City of Atlanta (Fulton/DeKalb Counties) Jurisdictional HIV Prevention Plan development began with a series of community engagement meetings, hosted by Fulton County Department of Health and Wellness High Impact HIV Prevention Program and facilitated by HealthHIV, a national organization that provides capacity building and technical assistance for health departments. The meetings were convened to engage community stakeholders in the identification and prioritization of innovative HIV prevention strategies to address the high burden of HIV in the jurisdiction. A two-day and one-day follow-up community engagement meetings, held September 27 and 28, and October 17, 2012, were utilized (See Attachment C for Full Report). 31 The intended outcomes of the community engagement meetings were to: 1. Increase stakeholder understanding of the changing HIV prevention, care, and treatment landscape, including high impact HIV prevention and National HIV/AIDS Strategy. 2. Identify community successes and challenges in implementing HIV prevention strategies. 3. Inform Fulton and DeKalb counties regarding activities, strategies, and programmatic directions in addressing the HIV prevention needs of the community. 4. Recommend community strategies for inclusion in the Fulton and DeKalb Counties HIV Prevention Jurisdictional and Comprehensive Plans (Figure 7). 31 HealthHIV Collaborating to Implement High Impact HIV Prevention: Fulton/DeKalb Counties Community Forum Engagement Report, October 2012

37 Page36 Figure 7. Process for Convening Community Engagement Meetings (September 27-28, 2012, and October 17, 2012). Jurisdictional HIV Prevention Community Engagement Planning Process Step One Organizational Infrastructure Assessment Step Two Stakeholder Identification & Recruitment Step Three Engage Community & Create Ownership for Process Step Four Results-oriented Engagement Process Step Five Jurisdictional Plan Development, Implementation and Monitoring Lead organization (Fulton County Department of Health and Wellness) begins by organizing and preparing to implement the community engagement process. Assessing structural, human and financial resource capacity. Partners, stakeholders, and community residents recruited to participate in the community engagement process. Participation will require a high level of commitment to participate in the planning process Community Engagement meeting was convened. A shared vision and common values were discussed. Participants were asked questions such as, "what would you like our community to look like in 5 years as it relates to HIV?", What does the health status of our community look like? etc. A list of challenges were identified. Once the list of challenges and opportunities were generated from the participants, the next step was to identify strategic issues. During this meeting, participants identified linkages between the issues to determine the most critical areas that must be addressed for the community to achieve its vision. After the issues have been identified, participants formulated goals and strategies for addressing each issue. The participants returned for another meeting of the community engagement process. The purpose of this meeting was to allow participants to finalized the goals, strategies, and objectives for the jurisdictional plan. The goals, strategies and objectives are placed in the Jurisdictional HIV Prevention Plan. The plan is disseminated to the community engagement participants for review and feedback. The plan is reviewed by the Jurisdictional HIV Prevention Planning Group for a letter of concurrence. HIV Planning Group All funded jurisdictions to include the fifty states, eight cities (Atlanta, Baltimore, Chicago, Houston, Los Angeles, New York, Philadelphia, and San Francisco), the District of Columbia, Puerto Rico, the Virgin Islands, and the United states Affiliated Pacific Island jurisdictions are required to have in place a planning process that includes the development of the City of Atlanta (Fulton/DeKalb Counties) Jurisdictional HIV Prevention Plan and the establishment of an HIV Planning Group (formerly HIV Community Planning Group). Fulton County formed and now operates a 33 member jurisdictional HIV prevention planning group that develops a plan to address for HIV prevention needs across Fulton and DeKalb Counties (Figures 8, 9, and 10). The City of Atlanta (Fulton/DeKalb Counties) Jurisdictional HIV Prevention Planning Group (JPG) is responsible for developing an engagement process for the jurisdiction. The JPG also participates in the development or update the local health department Jurisdictional HIV Prevention Plan and participates as a partner with the local health department to improve the impact of HIV prevention efforts with the jurisdiction (Fulton/DeKalb Counties), see Attachment A for JPG. (Figures 8, 9, and 10).

38 Page37 Figure 8. Figure 9. Figure 10

39 Page38 CITY OF ATLANTA (FULTON/DEKALB COUNTIES) JURISDICTIONAL HIV PREVENTION PLAN REQUIRED PROGRAM PLAN COMPONENTS This section outlines the specific goals, strategies and objectives the jurisdiction will follow to achieve the goals of the National HIV/AIDS Strategy. This section also describes how the plan goals, strategies and objectives will be measured.

40 Page39 The City of Atlanta (Fulton/DeKalb Counties) Jurisdictional HIV Prevention Plan, and the proposed interventions, goals, strategies and objectives align with the National HIV/AIDS Strategy such as: 1) Reducing New Infections; 2) Increasing Access to care and Improving Health Outcomes for People Living with HIV; and 3) Reducing HIV-Related Disparities and Health Inequities 32. JURISDICTIONAL HIV PREVENTION PLAN REQUIRED PROGRAM PLAN COMPONENTS A. HIV TESTING IN HEALTHCARE AND NON-HEALTHCARE SETTINGS Required Intervention #1: Routine, Opt-Out screening for HIV in clinical settings Goal 1: Increase the number of residents in Fulton/DeKalb Counties who receive Funding source: routine HIV screening as part of ongoing medical care. CDC-DHAP Strategy 1: Identify clinical providers and zip codes with highest burden of HIV disease for routine opt- HIV testing. Strategy 2: Identify existing training materials regarding routine HIV testing in clinical settings to promote HIV testing into routine medical care and/or develop provider training materials on routine HIV testing in the clinical settings. Strategy 3: Develop a MOU with the Southeast AIDS Education and Training Center (SEATEC) to provide routine HIV testing education. Strategy 4: Provide training, capacity building and technical assistance to healthcare providers in Fulton/DeKalb Counties to increase routine HIV testing in clinical settings. Strategy 5: Identify types of social media technologies proper to distribute messages encouraging routine HIV testing in the clinical settings. Strategy 6: Develop social media messages encouraging routine HIV testing in the clinical settings. Strategy 7: Identify and partner with medical and nursing associations. Strategy 8: Develop and utilize a data tracking tool to monitor the number of clinical settings implementing routine HIV testing. Objective 1: By December 31, 2012, develop a list of clinical providers to encourage and conduct routine HIV testing. Objective 2: By December 31,, provide routine HIV testing education to selected healthcare providers. Objective 3: By December 31,, disseminate messages via selected social media technologies (using at least 3 different social media technologies) to encourage routine HIV testing in the clinical setting. Objective 4: By December 31,, distribute brochures, pamphlets, etc., on HIV testing in medical settings through partnership with medical and nursing associations. Objective 5: By December 31,, establish a data tracking system and monitor the number of HIV testing in the clinical setting. Data sources: Monthly Fulton and DeKalb HIV test data reports; Ryan White program; participant evaluations 32 The National HIV/AIDS Strategy (NHAS) released by the White House on July 13, 2010 is the nation s first-ever comprehensive coordinated HIV/AIDS roadmap with clear and measurable targets to be achieved by By aligning our efforts with the National HIV/AIDS Strategy, we strive to reduce HIV transmission and better support people living with HIV and their families. Source: NHAS Fact Sheet, 2012

41 Page40 Goal 2: Increase the number of HIV tests provided in emergency rooms located in Funding source: high prevalence communities. CDC- DHAP Strategy 1: Collect the information regarding current policies in emergency rooms in Fulton/DeKalb Counties, and identify any barriers to implement routine HIV testing. Strategy 2: Identify and list the names of emergency departments in Fulton/DeKalb Counties. Strategy 3: Identify possible approaches to improve routine HIV testing in emergency rooms. Strategy 4: Contact identified emergency departments and assesses their needs for implementing routine HIV testing. Strategy 5: Work with emergency departments to establish HIV testing protocols to ensure that HIV tests are routinely provided to emergency room patients. Strategy 6: Assign Disease Invention Specialist (DIS) weekly to emergency rooms to conduct partner services on individuals testing HIV-positive. Strategy 7: Provide training, capacity building and technical assistance to healthcare providers in emergency departments to increase routine HIV testing. Objective 1: By February 28, 2013, assess current policies related to routine HIV testing in emergency rooms in Fulton/DeKalb Counties. Objective 2: By May 3, 2013, build collaborative relationships with emergency departments and provide technical assistance to encourage routine HIV testing in the emergency rooms. Objective 3: By December 31,, increase the number of HIV tests provided by emergency rooms in Fulton/DeKalb Counties by 10%. Objective 4: By December 31,, assign Disease Intervention Specialist (DIS) weekly to community-based organizations, medical settings or emergency rooms to conduct partner services on individuals testing HIV-positive. Responsible Parties: Fulton County Department of Health and Wellness High Impact HIV Prevention Program (HIPP); DeKalb County Board of Health; and funded community-based organizations. Data sources: Technical assistance logs, completed HIV counseling and testing forms, collaboration participation participate list, HIV testing data Required Intervention #2: HIV testing in non-clinical settings to identify undiagnosed HIV infection Goal 1: Ensure HIV testing is focused in non-clinical settings in areas with the Funding source: highest burden of disease. CDC- DHAP Strategy 1: Analyze client-level HIV testing data to assess outcomes of current HIV testing in non- clinical settings Strategy 2: Analyze epidemiologic and surveillance data to ensure HIV testing is targeted in the areas with the highest burden of disease. Strategy 3: Increase collaboration with community-based organizations by providing ongoing technical assistance visits and feedback. Strategy 4: Create a programmatic calendar for each program year to identify times and venues where agencies will conduct HIV testing and other services. Strategy 5: Develop and utilize a data tracking tool to monitor the number of HIV testing implemented in non-clinical settings. Strategy 6: Create and implement ongoing performance improvement plans of funded community based organizations and other providers who do not maintain a 2% newly diagnosed HIV positivity rate. Strategy 7: Conduct ongoing quarterly program performance reviews of all agencies funded to conduct targeted HIV testing in clinical and non- clinical settings.

42 Page41 Objective 1: By December 31, 2012, increase coordination of HIV testing and linkage-to-care programs in non-clinical settings. Objective 2: By December 31,, increase the number of new HIV testing service programs to target HIV testing in non-traditional settings and at non-traditional days and times by 10% compared to baseline Objective 3: By December 31,, minimize duplicates in services and HIV testing at non-clinical/non-traditional venues. Objective 4: By December 31,, partner with the State HIV Surveillance Department to review the client-level and epidemiological data to expand and enhance HIV testing efforts in the jurisdiction. Objective 5: Increase accountability for HIV testing through enhanced monitoring. Data sources: HIV testing forms, HIV testing data, Budget, contracts, Goal 2: Increase HIV testing among the populations at greatest risk for HIV infection Funding source: in Fulton/DeKalb Counties. CDC- DHAP Strategy 1: Request peer-to-peer technical assistance via UCHAPS to develop effective testing strategies for reaching African American MSM, injecting drug users, high-risk heterosexuals, and other high-risk, hard-to-reach populations. Strategy 2: Work with local community-based organizations that conduct targeted HIV testing to develop strategies to increase reach to high-risk populations. Strategy 3: Recruit and fund community-based organizations for new outreach testing programs serving the populations at greatest risk for HIV infection in the jurisdiction. Objective 1: By December 31, 2012, develop effective testing strategies for reaching African American MSM, injecting drug users, high-risk heterosexuals, and other high-risk, hard-to-reach populations. Objective 2: By December 30, 2012, develop and release Requests for Proposals (RFP) for new or expanded outreach testing programs. Objective 3: By December 31, 2012, establish contracts with community-based organizations and/or other service providers for new or expanded HIV testing programs. Data sources: Program plans, RFP, Contracts, HIV testing data Goal 3: Increase the percentage of newly-identified HIV-positive persons who learn Funding source: their serostatus and receive post-test counseling. CDC- DHAP Strategy 1: Shift to rapid testing in non-clinical testing programs that are currently utilizing conventional testing (as feasible and appropriate). Strategy 2: Pilot 5 th generation HIV testing technology when economically feasible. Objective 1: By December 31,, ensure that 80% of all newly-identified confirmed HIV-positive test results will be returned to the client. Objective 2: By December 31,, ensure that 75% of all newly-identified, confirmed HIV-positive tests results returned to the client are referred to partner services. Objective 3: By December 31,, ensure that 80% of newly-identified HIVpositive persons who learn their serostatus and receive post-test counseling are referred to medical care and confirm attendance to their first appointment Responsible Parties: Fulton County Department of Health and Wellness High Impact HIV Prevention Program (HIPP); DeKalb County Board of Health; and funded community-based organizations. Data sources: HIV Counseling and Testing forms, HIV testing data; STD*MIS, and SENDSS

43 Page42 Required Intervention #10: Implement STI screening according to current guidelines for HIVpositive persons Goal 1: Increase the percentage of persons living with HIV who received Funding source: recommended initial and ongoing STI screening as part of ongoing HIV medical care. CDC- DHAP Strategy 1: Inform medical providers about the latest STI Treatment Guidelines and the recommendations for initial and ongoing STI screening for HIV-positive persons in care. Strategy 2: Work with the Ryan White Planning Council, and provide and screen individuals accessing STD, TB and Ryan White Clinics for HIV. Strategy 3: Develop and use a tracking tool to monitor STI screening by HIV care providers and eligible community-based organizations, and provide technical assistance as needed. Objective 1: By December 31,, ensure that medical providers for HIV-positive clients are aware of the latest STI Treatment Guidelines and the recommendations for initial and ongoing STI screening for HIV-positive persons in care. Objective 2: By December 31,, partner with the Ryan White Planning Council to ensure information on STI screening for HIV-positive persons are disseminated annually. Objective 3: By December 31,, continue to implement standards for ensuring MSMs that access STI, TB and Ryan White Clinics are provided and screened for HIV. Objective 4: By December 31,, continue to implement standards for ensuring HIV-positive persons are screened for HIV by local primary care clinics and other providers. Responsible Parties: Fulton County Department of Health and Wellness High Impact HIV Prevention Program (HIPP); DeKalb County Board of Health; and funded community-based organizations Data sources: Meeting notes and distribution timeline Required Intervention #11: Implement prevention for perinatal transmission for HIV positive persons Goal 1: Increase the percentage of pregnant women who receive HIV testing during their first trimester; and Goal 2: Increase the percentage of women at high-risk for HIV infection during pregnancy who receive repeat testing in the third trimester. Funding source: CDC- DHAP Strategy 1: Identify and list any barriers to implement pre-natal testing and HIV reporting. Strategy 2: Identify, select, and visit a number OB/GYNs and/or providers treating pregnant women in Fulton and DeKalb Counties. Strategy 3: Provide OB/GYNs and/or providers with information regarding the CDC revised recommendations for HIV testing, information and support as to where to access information and trainings for the treatment of HIV-positive pregnant women (special emphasis on 3rd trimester testing). Strategy 4: Partner with the State HIV Surveillance Department to identify and report follow-up HIV prenatal cases and to ensure newborns have received post-natal care and HIV screening. Strategy 5: Assess existing collaborations and determine the strategic partners. Strategy 6: Visit labor and delivery hospitals and link women who test positive during birth to HIV care to ensure that the baby receives post-natal care and HIV testing (birth, 2 weeks, 6 weeks, and 4 months). Objective 1: By January 31, 2013, conduct an assessment of existing laws and gaps related to prenatal testing and HIV reporting. Data sources: State HIV

44 Page43 Objective 2: By February 28, 2013, disseminate recommendations regarding HIV testing intervals for high-risk pregnant women to all providers that provide prenatal care in the jurisdiction. Objective 3: By January 31, 2013, establish a tracking system to identify, contact, and provide follow-up to HIV-positive women who have recently given birth. Objective 4: By March 4, 2013, recruit partners from licensing boards, providers, professional associations and organizations to increase the capacity of preventing HIV infection through perinatal transmission. Objective 5: By December 31,, continue to partner with the state Perinatal Workgroup. Objective 6: By December 31,, continue to support outreach and HIV/STI partner services to provide HIV testing to high-risk women and connect pregnant women to prenatal care. Responsible Parties: Fulton County Department of Health and Wellness High Impact HIV Prevention Program (HIPP); DeKalb County Board of Health; and funded community-based organizations. Surveillance Case Reporting Forms, Notes B. HIV PREVENTION WITH POSITIVES Required Intervention #6: Implement linkage to care, treatment and prevention service for those testing HIV-positive and not currently in care Goal 1: Increase the percentage of HIV-positive persons who are successfully linked Funding source: to HIV medical care and support services. CDC- DHAP Strategy 1: Coordinate between HIV testing programs, linkage to care programs and HIV care providers to support effective referral and linkage to care. Strategy 2: Refer all confirmed HIV-positive persons to medical care and confirm attendance to their first appointment. Strategy 3: For all persons testing HIV-positive or currently living with HIV/AIDS who are linked to care and treatment, provide brief prevention intervention services. Strategy 4: Ensure continuity of care among persons living with AIDS. Strategy 5: Ensure that newly-identified, confirmed HIV-positive persons tested in clinical and nonclinical settings who regularly visit a HIV clinic or HIV medical care providers are referred for partners services, when eligible. Objective 1: By December 31, 2012, develop and implement Red Carpet linkage to care services to persons newly diagnosed with HIV. Objective 2: By December 31,, increase linkage to care among newly diagnosed individuals in the jurisdiction by 10% compared to baseline Objective 3: By December 31,, increase the proportion of newly-diagnosed persons linked to clinical care within three months of their diagnosis by 10% compared to baseline Objective 4: By December 31,, increase the percentage of HIV-positive persons who are in continuous care (at least 2 visits for routine HIV medical care in 12 months) by 10% compared to baseline Objective 5: By December 31,, reduce the proportion of individuals who have tested positive for HIV, but who are not in care by 10% annually (50% baseline). Data sources: CareWare, CD4, viral loads, appointments

45 Page44 Responsible Parties: Fulton County Department of Health and Wellness High Impact HIV Prevention Program (HIPP); DeKalb County Board of Health; and funded community-based organizations. Required Intervention #7: Implement interventions or strategies promoting retention in or engagement in care for HIV-positive persons Goal 1: Develop and support innovative providers and programs that improve Funding source: access to HIV care and treatment. CDC- DHAP Strategy 1: Implement linkage/retention collaboration with other HIV service providers in the jurisdiction. Strategy 2: Identify individuals in need of re-linkage to care and address re-linkage to care. Strategy 3: Contact each person that has fallen out of care for participation in Anti-Retroviral Treatment and Access to Services (ARTAS) individual-level behavioral intervention sessions. Strategy 4: Assess the percentage of Ryan White clients who are in continuous care and provide technical assistance as needed. Objective 1: By March 22, 2013, launch coordinated evidenced-based linkage/retention collaboration with other HIV services providers in the jurisdiction. Objective 2: April 1, 2013, apply HIV surveillance and HIV Care Data Matching Protocols to identify individuals in need of re-linkage to care, as well as the provider-and system-based factors that precipitated falling out-of-care. Objective 3: By December 31,, increase the number of people participating in in ARTAS individual-level behavioral intervention sessions by 10% annually. Objective 4: Increase the percentage of Ryan White clients who are in continuous care and have technical assistance by utilizing clinical quality management (CQM) mechanisms by 10% annually. Responsible Parties: Fulton County Department of Health and Wellness High Impact HIV Prevention Program (HIPP); DeKalb County Board of Health; and funded community-based organizations. Data sources: CareWare, ehars, Mitchell and McCormick, STD- MIS, and Ryan White Appointment Scheduler Required Intervention #8: Implement policies and procedures that will lead to the provision of antiretroviral treatment in accordance with the current guidelines for HIV positive persons Goal 1: Maintain and monitor standards of care that support the provision of Funding source: treatment in accordance with Public Health Service (PHS) guidelines CDC- DHAP Strategy 1: Utilize data from the State Department of Public Health, and the local health department HIV Primary Care Clinic AIDS Drug Assistance Program (ADAP) to issue periodic reports to providers on compliance with PHS guidelines. Strategy 2: Utilize webinars to provide the information about the PHS guidelines. Strategy 3: Meet with local health department Ryan White Primary Care Clinic Pharmacist and discuss using the Med Dispensing System. Strategy 4: Continue to monitor compliance with PHS guidelines through clinical record reviews conducted by the State Department of Public Health and Ryan White as part of Quality Management site visits with funded providers. Objective 1: By January 31, 2013, increase the awareness of providers in Fulton and Data sources:

46 Page45 DeKalb Counties about the PHS guidelines. Objective 2: By January 31, 2013, discuss opportunities to develop mechanisms for utilizing the Med Dispensing System to monitor compliance with PHS guidelines. Objective 3: By December 31,, continue the provision of clinical record reviews conducted by the State Department of Public Health and Ryan White for compliance with standards of care (including PHS guidelines). Responsible Parties: Fulton County Department of Health and Wellness High Impact HIV Prevention Program (HIPP); DeKalb County Board of Health; and funded community-based organizations. Site-visit reports, meeting records Required Intervention #9: Implement interventions or strategies promoting adherence to antiretroviral medications for HIV positive persons Goal 1: Increase the percentage of HIV-positive persons who are adherent to their Funding source: antiretroviral treatment regimen. CDC- DHAP Strategy 1: Identify the list of HIV-positive persons and monitor their adherence to antiretroviral treatment. Strategy 2: Conduct ADAP orientations for newly diagnosed and recently enrolled HIV-positive persons in care. Strategy 3: Monitor persons newly diagnosed with HIV about their Red Carpet linkage to care services status. Objective 1: By February 28,, increase the proportion of HIV-positive persons on antiretroviral therapy for more than 3-months with undetectable viral load by 20% (from 60% to 80%), thereby contributing to reductions in new HIV infections in the jurisdiction. Objective 2: By December 31,, work with the local health department Ryan White Primary Care Clinic ADAP Program and provide ADAP orientations for newly diagnosed and recently enrolled HIV-positive persons in care. Objective 3: By December 31,, continue to offer Red Carpet linkage to care services to persons newly diagnosed with HIV. Objective 4: By December 31,, continue to offer Patient Navigators to assist HIV-positive persons adhere to their antiretroviral treatment regimen. Responsible Parties: Fulton County Department of Health and Wellness High Impact HIV Prevention Program (HIPP); DeKalb County Board of Health; and funded community-based organizations. Data sources: CareWare, ehars, Mitchell and McCormick (M & M)

47 Page46 Required Intervention #12: Implement ongoing partner services for HIV-positive persons Goal 1: Increase the number of newly-diagnosed HIV-positive persons who are Funding source: provided with HIV/STI partner services. CDC- DHAP Strategy 1: Identify providers in the jurisdiction who are diagnosing HIV-positive persons and not currently requesting HIV/STI partner services for their clients. Strategy 2: Conduct targeted provider outreach to educate private providers and community-based organizations in high prevalence areas in the jurisdiction about the benefits of HIV/STI partner services and mechanisms for requesting follow-up for their clients. Strategy 3: Provide targeted providers with trained HIV/STI partner services field staff. Strategy 4: Reduce barriers related to the initiation of partner services for newly-diagnosed HIVpositive persons. Objective 1: By December 31, 2012, assess the effectiveness of current mechanisms for HIV/STI partner services referrals by private providers and community-based organizations. Objective 2: By December 31,, increase the number of providers to implement HIV/STI partner services for their clients by 10% compared to baseline Objective 3: By December 31,, increase the number of newly-diagnosed HIVpositive persons who are provided HIV/STI partner services by 10% compared to baseline Goal 2: Increase the quality and effectiveness of HIV/STI partner services Data sources: STD-MIS, SENDSS, Partner service logs and field records Funding source: CDC- DHAP Strategy 1: Collect data regarding partner services data using SENDSS. Strategy 2: Manage and analyze data to identify whether HIV/STI partner services are provided as planned. Objective 1: By December 1, 2012, participate in state training in preparation for transition to SENDSS. Objective 2: By December 31, 2012, transition from STD-MIS to SENDSS in Fulton County. Objective 3: By December 31, 2012, develop and utilize a data tracking tool based on the data from SENDSS and monitor the status of HIV/STI partner services Responsible Parties: Fulton County Department of Health and Wellness High Impact HIV Prevention Program (HIPP); DeKalb County Board of Health; and funded community-based organizations. Data sources: SENDSS data system

48 Page47 C. CONDOM DISTRIBUTION Required Intervention #3: Conduct targeted based condom distribution to HIV positive persons and persons at highest risk for acquiring HIV infection Goal 1: Increase the number of condoms distributed to HIV-positive persons and Funding source: persons at highest risk of acquiring HIV infection. CDC- DHAP Strategy 1: Make free condoms available to agencies and organizations in the jurisdiction that service high risk negative persons. Strategy 2: Identify and recruit clinical and non-clinical agencies to distribute condoms Strategy 3: Develop a campaign to promote condom use in clinical and non- clinical settings using YouTube (link distribution mobile applications/social media), social networking sites; sex clubs (Swingers), provider offices, college/university freshman orientation, etc. Strategy 4: Review available data sources to identify and recruit additional agencies, i.e., clinical and non-clinical settings, and venues that can distribute condoms to HIV-positive persons and persons at highest risk of acquiring HIV infection. Strategy 5: Develop and use a data tracking tool to track condom distribution. Strategy 6: Develop and disseminate education materials for correct condom use. Strategy 7: Provide female condoms for HIV-positive and high-risk persons. Objective 1: Increase the number of condoms distributed in jurisdiction - Fulton/DeKalb Counties by 10% annually. Objective 2: Increase the number of agencies, clinics, and other sites distributing condoms to HIV-positive persons and persons at the highest risk of acquiring HIV infection by 10% annually. Objective 3: By February 28, 2013, begin expanded condom distribution in partnership with community-based organizations, STI clinics, private clinical providers, clubs, bars, beauty and barber shops, and other clinical and non- clinical agencies, and venues that serve high-risk persons. Objective 4: By January 31, 2013, improve the data collection process to effectively track condom distribution to high-risk persons. Objective 5: By December 31,, increase education and availability of female condoms for HIV- positive and high-risk persons. Objective 6: By December 31,, distribute more than 9,064,509 condoms to HIV-positive, high-risk negative persons and the general population in the jurisdiction. Data sources: Condom distribution log; Number of condoms targeted to specific populations (High-risk HIV negatives/unkno wn, HIV positives, general population)

49 Page48 Goal 1: Increase correct and consistent condom use among HIV-positive persons Funding source: and persons at highest risk for acquiring HIV infection in the jurisdiction CDC- DHAP Strategy 1: Set targets and standards for prevention programs to distribute condoms and conduct condom education. Strategy 2: Develop and provide new educational materials and approaches to promote condom use by HIV-positive persons and specific target populations at high risk. Strategy 3: Strengthen HIV education along with condoms availability for those re-entering the community from prison or jails. Strategy 4: Increase education and availability of female condoms for HIV positive and high risk populations. Objective 1: By January 31,, began conducting weekly peer education trainings within social networks of high risk population groups (African American MSM, IDU, high risk heterosexuals and other high-risk, hard to reach populations). Objective 2: By January 31,, implement weekly behavioral, biomedical and structural interventions to HIV-negative persons at highest risk for HIV that present to the STD/TB clinic each day. Objective 3: By December 31,, ensure that HIV negative persons at highest risk for HIV will be offered a behavioral, biomedical or structural intervention, i.e., RESPECT, Personalized Cognitive Risk Reduction Counseling Intervention, VOICES/VOCES, Safe in the City, and/or Focus on the Future. Responsible Parties: Fulton County Department of Health and Wellness High Impact HIV Prevention Program (HIPP); DeKalb County Board of Health; and funded community-based organizations. Data sources: Questionnaires, log of HC& NHC, # & % HIV (+) persons & HIVhigh risk people receiving PCC, RESPECT, VOICES, Safe in the City, interventions D. STRUCTURAL AND POLICY INITIATIVES Required Intervention #5: Efforts to change existing structures, policies, and regulations that barriers to creating an environment for optimal HIV prevention, care and treatment Goal 1: Identify and prioritize options for minimizing or overcoming internal weaknesses to creating an environment for optimal HIV prevention, care, and treatment. Funding source: CDC- DHAP Strategy 1: Identify the barriers within the targeted population living within the high risk zip codes to participating in routine Pre-natal screenings. Strategy 2: Identify barriers to partnering with adult and juvenile correctional institutions physically located within the jurisdiction regarding HIV testing. Strategy 3: Increase the awareness of the importance of receiving prenatal care in the targeted zip codes, so that mothers opt to participate in prenatal care and thus create the opportunity to be screened for HIV. Strategy 4: Assist the local chapters of professional associations (American Medical Association, nursing schools, Nursing assistance training programs, etc.) in promoting adherence to testing (prenatal and opt-out) recommendations. Strategy 5: Close the loop in data reporting such that healthcare providers can realize a benefit to complying with testing regulations. Objective 1: By January 4, 2013, create an advocacy package targeting institutions located within the high risk areas that provide obstetric and delivery services to Data sources: Meeting notes,

50 Page49 persons from high risk areas. Objective 2: By January 4, 2013, create an advocacy package and/or advocacy campaign targeting healthcare providers within the jurisdiction who have the capacity to perform HIV/AIDS testing of persons from the targeted high risk areas. Objective 3: By January 18, 2013, work in concert with others advocating in the areas of adolescent health and teen pregnancy prevention to ensure that patient rights messaging with regards to HIV prevention and treatment are included in their advocacy efforts. Objective 4: By February 29,, compile into one resource, existing policies that present as barriers to, and existing policies that would favor or facilitate the creation of a jurisdictional coordinated effort to ensure incarcerated persons within a correctional facility and upon leaving a correctional facility know their status. packages of information Goal 2: To improve, on the institutional/ local/state level, the legislators/policy makers use of evidence-based data in decision making by facilitating access to this data. Funding source: CDC- DHAP Strategy 1: Identify and provide advocacy support to HIV/AIDS stakeholders that work with our legislative liaison. Strategy 2: Identify and provide advocacy support to HIV/AIDS stakeholders in clinical settings within the jurisdiction Strategy 3: Create a mechanism (web portal/ work group) where schools of health policy can link with advocates and share resources (interns, data, etc.). Objective 1: By December 31, 2013, supply the Fulton County Legislative Liaison with up-to-date evidence-based information on HIV counseling, testing, and care. The success of this objective is to be measured by the percentage of on-time delivery of responses to liaison requests. Objective 2: By June 30, 2013, create a portal with aggregate level data accessible by these supportive individuals to assist them in their advocacy efforts and their ability to transfer knowledge of evidence-based data. Objective 3: By December 30, 2013, work with the legislative liaison to educate legislators on Medicaid expansion as is relates prevention and care for HIV-positive persons. Responsible Parties: Fulton County Department of Health and Wellness High Impact HIV Prevention Program (HIPP); and Fulton County Legislative Liaison. Data sources: Meeting notes, packages of information

51 Page50 E. OTHER SUPPORTED ACTIVITIES Recommended Intervention #17: Clinic-wide or provider-delivered evidence-based HIV prevention interventions for HIV-positive clients and clients at highest risk of acquiring HIV Goal 1: Increase the percentage of high risk negative persons at risk for HIV who receive prevention interventions as part of access to medical care Strategy 1: Conduct provider-based HIV prevention intervention (i.e., Partnership for Health, Personalized Cognitive Counseling, etc.) Objective 1: By December 31,, all HIV negative persons at highest risk for HIV, that seek services in a STI/TB/Ryan White clinic, will be screened and offered a evidenced-based intervention, i.e., RESPECT, Personalized Cognitive Risk Reduction Counseling Intervention, VOICES/VOCES, Safe in the City, and Partnership for Health, during each clinic visit. Objective 2: By December 31, 2014, formalize plans for evaluation of the clinicwide or provider-delivered evidence-based HIV prevention interventions for HIVpositive clients and clients at highest risk of acquiring HIV. Responsible Parties: Fulton County Department of Health and Wellness High Impact HIV Prevention Program (HIPP); DeKalb County Board of Health; and funded community-based organizations. Funding source: CDC- DHAP Data sources: # clients participating in interventions, evaluation analysis Recommended Intervention # 16: HIV and Sexual Health Communication or Social Marketing Campaigns targeted to relevant audiences Goal 1: To implement targeted, multi-platform social media outreach HIV testing Funding source: and prevention campaigns for targeted groups in Fulton and DeKalb Counties. CDC- DHAP Strategy 1: Develop and implement a social marketing campaign (i.e., I Know My Status) Strategy 2: Mobilize community-based organizations to review and implement social marketing tools to support and promote community use of credible, free, downloadable HIV media technology such as widgets, podcasts, and Real Simple Syndication (RSS Feeds). Strategy 3: Partner with agencies and others to script personalized HIV testing and prevention messages for persons likely to respond to HIV testing options and HIV prevention messages. Strategy 4: Designate social media and marketing teams to engage individuals around all HIV prevention services. Strategy 5: Use auto-texting technology to build an online community and promote HIV prevention activities (i.e., HIV testing mobile unit, HIV prevention events, etc.) Strategy 6: Utilize outside marketing and advertising agencies to create and disseminate cultural appropriate messages for targeted populations concerning HIV testing, condom distribution, and Prevention for Positives. Strategy 7: Work with the State Department of Public Health HIV Section to increase the distribution of HIV and sexual health social marketing campaigns (i.e., Greater than AIDS, Taking Control) Strategy 8: Work with the Centers for Disease Control and Prevention to increase the distribution of HIV and sexual health social marketing campaign (i.e., Testing Makes Us Stronger). Strategy 9: Develop a tracking system that keeps records of social marketing campaign material distributions to service providers and other agencies in the jurisdiction. Objective 1: By July 1, 2013, establish a contract with a marketing firm. Objective 2: By July 30, 2013, convene a Community Advisory Group comprised of Data sources: Social Media

52 Page51 persons living with HIV to partner in the development and implementation of a social marketing campaign for the jurisdiction. Objective 3: By October 30, 2013, recruit and select African American MSM, transgender persons, high-risk negative persons and the general population as campaign spokespersons. Objective 4: By November 29, 2013, mobilize community-based organizations to review and implement social marketing tools to support and promote community use of credible, free, downloadable HIV media technology such as widgets, podcasts, and Real Simple Syndication (RSS Feeds). Objective 5: By December 31, 2013, fully implement I Know My Status campaign. Responsible Parties: Fulton County Department of Health and Wellness High Impact HIV Prevention Program (HIPP); DeKalb County Board of Health; and funded community-based organizations metrics (e.g. Likes, Followers, comments, etc.) Qualitative evaluations, tracking systems Required Intervention #4: Provision of Post-Exposure Prophylaxis to populations at greatest risk Goal 1: Issue guidance related to the provision on non-occupational post-exposure Funding source: prophylaxis (npep) to medical providers in the jurisdiction. CDC- DHAP Strategy 1: Develop jurisdictional guidelines for non-occupational post-exposure prophylaxis for medical providers in the jurisdiction. Strategy 2: Discuss specific capacity building assistance needs or training on nprep-related activities. Objective 1: By January 31, 2013, develop a MOU with the Southeast AIDS Training and Education Center (SEATEC) to develop webinars, workshops and trainings on non-occupational post-exposure prophylaxis for medical providers in the jurisdiction. Objective 2: By April 30, 2013, review CDC guidelines and best practices for the provision of post-exposure prophylaxis after sex, injection-drug use or other nonoccupational exposure to HIV. Objective 3: By April 30, 2013, incorporate communications about nprep into the services provided to MSMs and to high risk heterosexual persons presenting at clinical settings. Objective 4: By July 31, 2013, disseminate guidelines to medical providers in the jurisdiction. Responsible Parties: Fulton County Department of Health and Wellness High Impact HIV Prevention Program (HIPP); DeKalb County Board of Health; and funded community-based organizations. Data sources: MOU, Guidelines, Distribution logs and list serves

53 Page52 Recommended Intervention #20: Integrated hepatitis, TB and STI testing, partner services, vaccination, and treatment for HIV infected persons, HIV-negative persons at highest risk of acquiring HIV, and injection drug users according to existing guidelines Goal 1: Increase the integration of HIV, STI, TB, viral hepatitis screening and/or testing (as clinically indicated) in HIV testing programs and in the local health departments Fulton/DeKalb Counties. Funding source: CDC- DHAP Strategy 1: Coordinate integrated hepatitis, TB, and STI screening, and partner services, for HIVpositive persons. Strategy 2: HIV-positive persons that visit healthcare settings monthly is screened for Hepatitis, TB and STI and offered partner services. Objective 1: By November 14, 2012, ensure that all HIV-positive clients that access HIV medical care are screened for viral hepatitis as based on Ryan White Program protocol. Objective 2: By December 31, 2012, review client-level HIV and STI testing data to assess the percentage of high-risk clients who are receiving integrated HIV, STI and viral hepatitis testing. Objective 3: By December 31, 2012, review results with testing providers and develop plans to increase the provision of integrated HIV, STI and viral hepatitis testing. Objective 4: By July 31, 2013, implement plans to increase the provision of integrated HIV, STI, TB and viral hepatitis screening and/or testing (as clinically indicated). Responsible Parties: Fulton County Department of Health and Wellness High Impact HIV Prevention Program (HIPP); DeKalb County Board of Health; and funded community-based organizations. Data sources: EvaluationWeb, STD-MIS, SENDSS

54 Page53 National HIV/AIDS Strategy National Strategic Goals This section is designed to highlight how the elements/strategies of the City of Atlanta (Fulton/DeKalb Counties) Jurisdictional HIV Prevention Plan work together with specific goals, objectives and quality assurances to achieve goals set forth in the National HIV/AIDS Strategy

55 Page54 National HIV/AIDS Strategy National Strategic Goals The National HIV/AIDS Strategy (NHAS) released by the White House on July 13, 2010, is the nation s first-ever comprehensive coordinated HIV/AIDS roadmap with clear and measurable targets to be achieved by By aligning our efforts with the National HIV/AIDS Strategy, we strive to reduce HIV transmission and better support people living with HIV and their families. The proposed interventions, goals, strategies and objectives align with the National HIV/AIDS Strategy such as: 1) Reducing New Infections; 2) Increasing Access to care and Improving Health Outcomes for People Living with HIV; and 3) Reducing HIV-Related Disparities and Health Inequities. This section is designed to highlight how the elements/strategies of the City of Atlanta (Fulton/DeKalb Counties) Jurisdictional HIV Prevention Plan work together with specific goals, objectives and quality assurances to achieve goals set forth in the National HIV/AIDS Strategy (NHAS). It is acknowledged that each jurisdiction is in a different position regarding their capacity to reach these goals. Nevertheless, a critical step toward ensuring that maximum effort is given to achieving these national goals is to make them a key component in the planning process. HIV/AIDS remains an important public health problem in Georgia. In 2009, Georgia had one of the highest rates of persons living with a diagnosis of HIV infection in the United States at 32.9 per 100,000 persons. The Atlanta MSA comprised more than 50% of the state population in 2010, and had the highest percentage of people living with HIV/AIDS in the state (66%). From 2001 to 2010, 71% of new HIV/AIDS diagnoses in Georgia occurred among males. Seventy-four percent of new HIV/AIDS diagnoses were among Black, non-hispanics. Among Black, non-hispanics, those in the age group of years had the highest rate of new HIV/AIDS diagnoses. The HIV/AIDS epidemic in Georgia is primarily driven by sexual exposure, especially among men who have sex with men and high-risk heterosexuals. Injection drug use is also a high risk category, but less prevalent than sexual contact. Communicable diseases like sexually transmitted infections (STI) and Tuberculosis (TB) pose a risk for individuals who are infected with HIV in Georgia. STDs can increase the risk for HIV infection from 2 to 5 times. For example, syphilis leads to decreased CD4 T-cell counts and increased plasma viral load in patients chronically infected with HIV, and this has been linked to increased HIV transmission. Equally important, TB is a leading cause of morbidity and mortality for people with HIV/AIDS. People who are co-infected with HIV and TB are at an increased risk of reactivation of latent TB and acquisition of new opportunistic infections. 1. Reducing New HIV Infections There were 27,560 individuals living with HIV-Not AIDS or AIDS in the Atlanta Metropolitan Statistical Area (MSA) as of December 31, Of these individuals, 78% were male. Thirty-two percent of the individuals living with HIV-Not AIDS as of December 31, 2010, in the Atlanta EMA were years old. Twenty percent of the cases in the Atlanta MSA as of December 31, 2010 occurred in females. Of these females, 26% occurred in high-risk heterosexual (HRH). Sixty-eight percent of persons living with AIDS in the Atlanta MSA as of December 31, 2010 were Black, Non-Hispanic, and 59% of persons living with AIDS were MSM. To reduce new infections, the City of Atlanta, Fulton County Department of Health and Wellness, in partnership with DeKalb County Board of Health and community-based organizations will:

56 Page55 Identify clinical providers and zip codes with highest burden of HIV disease for routine opt-hiv testing; Identify existing training materials regarding routine HIV testing in clinical settings to promote HIV testing into routine medical care and/or develop provider training materials on routine HIV testing in the clinical settings; Develop a MOU with the Southeast AIDS Education and Training Center (SEATEC) to provide routine HIV testing education; Provide training, capacity building and technical assistance to healthcare providers in Fulton/DeKalb Counties to increase routine HIV testing in clinical settings; Identify types of social media technologies proper to distribute messages encouraging routine HIV testing in the clinical settings; Develop social media messages encouraging routine HIV testing in the clinical settings; Identify and partner with medical and nursing associations; Develop and utilize a data tracking tool to monitor the number of clinical settings implementing routine HIV testing; Collect the information regarding current policies in emergency rooms in Fulton/DeKalb Counties, and identify any barriers to implement routine HIV testing; Identify and list the names of emergency departments in Fulton/DeKalb Counties; Identify possible approaches to improve routine HIV testing in emergency rooms; Contact identified emergency departments and assesses their needs for implementing routine HIV testing; Work with emergency departments to establish HIV testing protocols to ensure that HIV tests are routinely provided to emergency room patients; Assign Disease Invention Specialist (DIS) weekly to emergency rooms to conduct partner services on individuals testing HIV-positive; Provide training, and capacity building and technical assistance to healthcare providers in emergency departments to increase routine HIV testing. Fulton County will also analyze client-level HIV testing data to assess outcomes of current HIV testing in non- clinical settings; Analyze epidemiologic and surveillance data to ensure HIV testing is targeted in the areas with the highest burden of disease; Increase collaboration with community-based organizations by providing ongoing technical assistance visits and feedback; Create a programmatic calendar for each program year to identify times and venues where agencies will conduct HIV testing and other services; Develop and utilize a data tracking tool to monitor the number of HIV testing implemented in non-clinical settings; Create and implement ongoing performance improvement plans of funded community based organizations and other providers who do not maintain a 2% newly diagnosed HIV positivity rate; Conduct ongoing quarterly program performance reviews of all agencies funded to conduct targeted HIV testing in clinical and non- clinical settings; Request peer-to-peer technical assistance via UCHAPS to develop effective testing strategies for reaching African American MSM, injecting drug users, high-risk heterosexuals, and other high-risk, hard-to-reach populations; Work with local community-based organizations that conduct targeted HIV testing to develop strategies to increase reach to high-risk populations; Recruit and fund community-based organizations for new outreach testing programs serving the populations at greatest risk for HIV infection in the jurisdiction; Shift to rapid testing in non-clinical testing programs that are currently utilizing conventional testing (as feasible and appropriate); and Pilot 5 th generation HIV testing technology when economically feasible. Fulton County will also inform medical providers about the latest STI Treatment Guidelines and the recommendations for initial and ongoing STI screening for HIV-positive persons in care; Work with the Ryan White Planning Council, and provide and screen individuals accessing STD, TB and Ryan White Clinics for HIV; Develop and use a tracking tool to monitor STI screening by HIV care providers and eligible community-based organizations, and provide technical assistance as needed; Identify and list any barriers to implement pre-natal testing and HIV reporting; Identify, select, and visit a number OB/GYNs and/or providers treating pregnant women in Fulton and DeKalb Counties; Provide OB/GYNs and/or providers with information regarding the CDC revised recommendations for HIV testing, information and support as to where to access information and trainings for the treatment of HIVpositive pregnant women (special emphasis on 3rd trimester testing); Partner with the State HIV

57 Page56 Surveillance Department to identify and report follow-up HIV prenatal cases and to ensure newborns have received post-natal care and HIV screening; Assess existing collaborations and determine the strategic partners; and Visit labor and delivery hospitals and link women who test positive during birth to HIV care to ensure that the baby receives post-natal care and HIV testing (birth, 2 weeks, 6 weeks, and 4 months). 2. Increasing Access to Care and Improving Health Outcomes for People Living with HIV Fulton County Government administers the Ryan White Part A program for the Atlanta Metropolitan Statistical Area (MSA) and is tasked with improving access to care and treatment for people who are HIV positive, but not in care. Efforts are in process to increase the number of people in care and treatment who have not been tested for HIV, but are HIV-positive, as well as those who know they are living with HIV, but are not in care. Fulton County Department of Health and Wellness (FCDHW) Communicable Disease Prevention Branch (CDPB) is a key partner in the EMA s linkage to care efforts. Furthermore, as the service provider for the largest number of persons living with HIV not-aids in the MSA, as well as the largest provider of HIV screenings in the MSA, FCDHW is positioned to play a key role in bridging medically underserved HIV positive individuals to care and treatment services. CDPB, in concert with the Primary Care Clinic (PCC) to provide primary care services to individuals who are HIV-positive, and to ensure that individuals receive the best preventive service and treatment possible whenever they interact with the PCC providers. The FCDHW/CDPB primary care services include the provision of 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, care of minor injuries, education and counseling on health and nutritional issues, continuing care and management of chronic conditions, and referral to and provision of specialty care. Primary medical care for the treatment of HIV infection includes the provision of care consistent with US Public Health Service Guidelines (USPHS). Care includes access to antiretroviral and other drug therapies, including prophylaxis and treatment of opportunistic infections and combination antiretroviral therapies. Service gaps were documented in a number of specific needs assessments/consumer surveys carried out by the Metropolitan Atlanta HIV Health Services Planning Council in the MSA during the past few years. Using data from the HIV/AIDS reporting system (ehars), the statewide laboratory database and the Georgia Department of Public Health, HIV Epidemiology Unit it has been estimated that 56% of PLWHA in the MSA had not received primary health care services during Apart from primary health care, there are also two other areas in which there are gaps in services. Data from the 2008 Atlanta MSA HIV Consumer Survey and the CAREWare database indicate 39% of PLWHA have mental health problems, specifically depression, but only 21% of clients at Part A funded service sites received mental health services during There are 10,485 persons with mental health needs. Data from the same sources indicate that 9% of PLWHA in the MSA (2,420) have substance abuse problems as a contributing factor in their infection and will need additional care. To increase access to care and improving health outcomes for people living with HIV, the City of Atlanta, Fulton County Department of Health and Wellness, in partnership with DeKalb County Board of Health and community-based organizations will: Coordinate between HIV testing programs, linkage to care programs and HIV care providers to support effective referral and linkage to care. Refer all confirmed HIV-positive persons to medical care and confirm attendance to their first appointment; For all persons

58 Page57 testing HIV-positive or currently living with HIV/AIDS who are linked to care and treatment, provide brief prevention intervention services; Ensure continuity of care among persons living with AIDS; Ensure that newly-identified, confirmed HIV-positive persons tested in clinical and non-clinical settings who regularly visit a HIV clinic or HIV medical care providers are referred for partners services, when eligible; Implement linkage/retention collaboration with other HIV service providers in the jurisdiction; Identify individuals in need of re-linkage to care and address re-linkage to care; Contact each person that has fallen out of care for participation in Anti-Retroviral Treatment and Access to Services (ARTAS) individual-level behavioral intervention sessions; Assess the percentage of Ryan White clients who are in continuous care and provide technical assistance as needed; Utilize data from the State Department of Public Health, and the local health department HIV Primary Care Clinic AIDS Drug Assistance Program (ADAP) to issue periodic reports to providers on compliance with PHS guidelines; Utilize webinars to provide the information about the PHS guidelines; Meet with local health department Ryan White Primary Care Clinic Pharmacist and discuss using the Med Dispensing System; Continue to monitor compliance with PHS guidelines through clinical record reviews conducted by the State Department of Public Health and Ryan White as part of Quality Management site visits with funded providers; Identify the list of HIV-positive persons and monitor their adherence to antiretroviral treatment; Conduct ADAP orientations for newly diagnosed and recently enrolled HIV-positive persons in care; Monitor persons newly diagnosed with HIV about their Red Carpet linkage to care services status; Identify providers in the jurisdiction who are diagnosing HIV-positive persons and not currently requesting HIV/STI partner services for their clients; Conduct targeted provider outreach to educate private providers and community-based organizations in high prevalence areas in the jurisdiction about the benefits of HIV/STI partner services and mechanisms for requesting follow-up for their clients; Provide targeted providers with trained HIV/STI partner services field staff; Reduce barriers related to the initiation of partner services for newly-diagnosed HIV-positive persons; Collect data regarding partner services data using SENDSS; and Manage and analyze data to identify whether HIV/STI partner services are provided as planned. 3. Reducing HIV-Related Disparities From the results of the unmet need analysis, it is clear that getting individuals into HIV primary care must be a continuing priority. In the 2008 Consumer Survey, consumers reported using medical and information services at high rates in the past 30 days (primary medical care 77% and antiretroviral medications 73%). Dental care (46%) was the most frequently reported service needed but not received. The most commonly reported barriers for consumers were personal (26%), followed by information (19%) and capacity (16%). Additional analysis revealed that capacity (20%) and other barriers (20%) were reported by consumers earning an annual income less than 100% of Federal Poverty Level (FPL). Information barriers were reported more frequently by Hispanics (33%), women (31%), and especially women of childbearing age (37%). Personal barriers, the most commonly reported of all, indicated the highest statistically significant rates for men (28%). Participants were asked screening questions regarding substance abuse and mental health. Of the 313 participants that completed the screening, 80 (26%) consumers were in need of additional substance abuse assessment and 136 (39%) were in need of additional mental health assessment. To reduce HIV-related disparities, the City of Atlanta, Fulton County Department of Health and Wellness, in partnership with DeKalb County Board of Health, community-based organizations and the City of Atlanta (Fulton/DeKalb Counties) Jurisdictional HIV Prevention Planning Group. Fulton County formed and now operates a 33 member jurisdictional HIV prevention planning group that develops a plan to address for HIV prevention needs across Fulton and DeKalb Counties. The City of Atlanta (Fulton/DeKalb Counties) Jurisdictional HIV Prevention Planning Group is responsible for developing an engagement process for the jurisdiction. The

59 Page58 Jurisdictional HIV Prevention Planning Group also participates in the development or update the local health department Jurisdictional HIV Prevention Plan and participates as a partner with the local health department to improve the impact of HIV prevention efforts with the jurisdiction (Fulton/DeKalb Counties) will: Identify the barriers within the targeted population living within the high risk zip codes to participating in routine Pre-natal screenings; Identify barriers to partnering with adult and juvenile correctional institutions physically located within the jurisdiction regarding HIV testing; Increase the awareness of the importance of receiving prenatal care in the targeted zip codes, so that mothers opt to participate in prenatal care and thus create the opportunity to be screened for HIV; Assist the local chapters of professional associations (American Medical Association, nursing schools, Nursing assistance training programs, etc.) in promoting adherence to testing (prenatal and opt-out) recommendations; Close the loop in data reporting such that healthcare providers can realize a benefit to complying with testing regulations; Identify and provide advocacy support to HIV/AIDS stakeholders that work with our legislative liaison; Identify and provide advocacy support to HIV/AIDS stakeholders in clinical settings within the jurisdiction; and Create a mechanism (web portal/ work group) where schools of health policy can link with advocates and share resources (interns, data, etc.).

60 Page59 ATTACHMENTS

61 Page60 Attachment A: List of Jurisdictional Planning Group MEMBER ORGANIZATION CATEGORY TYPE B.T. Fulton County Resident Trans Dennis Meredith Tabernacle Baptist Church Faith Community Derek Duncan Trinity Community Ministries Substance Abuse Dolph Ward Goldenburg Living Room, Inc. HOPWA Dr. Elleen Yancey Morehouse School of Medicine Academia Dr. Harvinder Makkar Travelers Aid of Metropolitan Atlanta, Inc. Homeless Services Dr. Natasha Travis Dr. Natasha Travis Mental Health Dr. Phillip Finley Argosy University Instructor Dwight Anderson Ryan White Planning Council Ryan White Planning Group/PLWHA Edwin Blount Fulton County Resident MSM/PLWHA James Freeman Jeff Graham Southside Medical Center Georgia Equality/Equality Foundation of Georgia Community Health Center/Clinical Care Provider Jeff McDowell Atlanta Harm Reduction Center IDU Policy Kimberly Hagen Rollins School of Public Health Academic Institution Margaret Renfroe DeKalb Addition Center Substance Abuse Melvin Gaye Fulton County Jail Corrections Michelle Lawrence Underground Atlanta Business/Labor Community Health Center/Clinical Care Patricia Parsons Saint Joseph Mercy Care Services of Atlanta Provider Rudolph H. Carn NAESM, Inc. MSM Tommie Lightfoot Holloway Fulton County Department of Health & Wellness Disease Intervention Specialist Valencia Beckley Fulton County Department of Health & Wellness Nursing Walter Bradley State Community Planning Group CPG/PLWHA Walter Hicks Fulton County Resident PLWHA Dr. Y. Omar Whiteside Georgia Department of Public Health Epidemiology Michelle Broussard Nutrition/WIC Program WIC Daniel Driffin Community MSM Rameses Fredrick Urban Socialites/Business MSM Lesbian, Bi-Sexual, Transgender, Terence McPhaul Youth Pride Questioning Youth

62 Page61 Attachment B HIV Prevention Interventions Agency Fulton DeKalb HIV Testing Type HIV Prevention Services Effective Behavioral Interventions Aniz, Inc. x Conventional, oral Advocacy, counseling, case management, clothing, medical info., prevention education Condom distribution, VOICES, SISTA, 3MV Empowerment Resource Center x Conventional, oral, rapid HIV/STD prevention education, primary care linkages (PLWHA), pregnancy test, client advocacy Condom distribution, VOICES, SHILE, WILLOW Fulton County Dept. of Health & Wellness x Conventional, rapid HIV/STD prevention education, primary care linkages (PLWHA), support groups, TB screening, Safe in the City, VOICES, Condom distribution, Hope Atlanta/Traveler s AID X Oral, rapid Emergency services, shelter, food, case management Condom distribution, Planned Parenthood SE Inc. X Conventional, oral, Reproductive services, counseling, sexual health Condom distribution, rapid education, referrals, Center for Black Women s x Conventional Condom distribution, Wellness Saint Joseph Mercy Care- X Rapid, oral HIV/STI Prevention Education, Early Intervention Condom distribution, Edgewood Clinic, Primary Care & Dental Care, TB Screening, Case Management, Behavioral Health. EBIs VOICES, RESPECCT AID Atlanta X Conventional, rapid, oral Substance abuse, support groups, mental health, HIV prevention education, advocacy, case management Condom distribution, Healthy Relationships Making a Way Housing Inc. x Rapid, oral Emergency shelter, food pantry, case management, Condom distribution, life skills training, group counseling, computer classes NAESM Inc. X Oral, rapid Capacity building assistance, medical referrals, peer counseling, education and outreach Condom distribution, Positive Impact Inc. X Rapid, oral Substance abuse, support groups, mental health, drug and alcohol treatment education, HIV prevention education SisterLove Inc. X Conventional, Oral, rapid HIV prevention education, Positive Women s Leadership training, HIV treatment adherence education Condom distribution, CLEAR, Healthy Relationships, Community Promise Healthy Love Party Community Promise Healthy Love Youth Network, condom distribution, PrEP Condom distribution, West End Medical Center X Conventional, Oral, rapid Southside Medical Center X Conventional Condom distribution, Atlanta Harm Reduction Coalition x Conventional, oral, Hep A&B vaccinations, drug/alcohol treatment Safety Counts, Voices Inc. rapid assistance, TB screening, Hep C education

63 Page62 Agency Fulton DeKalb HIV Testing Type HIV Prevention Services Effective Behavioral Interventions Youth Pride Inc. X Rapid, oral Counseling, socialization groups, leadership Condom distribution, development, peer education, transgender services AIDS Research Consortium of x Rapid, oral Research, prevention education, referrals Condom distribution, Atlanta Essence of Hope X Rapid HIV prevention education, referrals, health education Condom distribution, Someone Cares Inc. of Atlanta x Rapid, conventional, oral HIV/AIDS/STD education & prevention, referral placement, POZ empowerment group, comprehensive condom distribution, VOICES, 3MV, D-UP, CRCS risk counseling services, outreach AIDS Atlanta Evolution Project x Rapid, conventional, oral Mpowerment, condom distribution Absolute Care Medical Center X Rapid, oral Primary medical care, peer counseling, STD clinic, Condom distribution social services, support groups, pharmacy Edgewood Medical Center, Inc. x Conventional Primary care, urgent care, health and wellness Condom distribution education, transgender health LaGender Inc. x N/A HIV/AIDS education, outreach services, prevention Condom distribution education, support groups Wholistic Stress Control Institute, Inc. X N/A Treatment services for HIV-positive individuals N/A

64 Page63 DeKalb County Agency Fulton DeKalb HIV Testing Type HIV Prevention Services Effective Behavioral Interventions DeKalb CSB Addiction Clinic X Rapid Substance abuse counseling, prevention education, Condom distribution, DeKalb CSB Richardson Health x Conventional, rapid Free condoms, nutrition, dental, prevention education, Condom distribution, Center medical care, mental health DeKalb County Board of Health T Conventional, rapid Free condoms, prevention education, dental, nutrition, Condom distribution, O Vinson Health Center transportation, medical care, mental health Atlanta Feminist Women s Health x Conventional, rapid Health education and risk reduction counseling, support Condom distribution, Center groups, community outreach, case management, referrals DeKalb Prevention Alliance Inc. x Oral Condom distribution, Recovery Consultants of Atlanta X Oral, rapid Street outreach, pre-treatment for substance abusers, Condom distribution, Inc. HIV prevention, partner violence, outpatient drug treatment STAND Inc. X Conventional, rapid Prevention and risk reduction counseling, support Condom distribution, CRCS groups, community outreach, case management, referrals Center for Pan Asian Community Services Inc. X Rapid Condom distribution, VOICES/VOCES AHF Citywide Project Inc. X Conventional, oral, Prevention and risk reduction counseling, care and Condom distribution, rapid treatment, support groups, community outreach Alpha and Omega HIV/AIDS X N/A Prevention, education, emotional support, mental health Condom distribution, Foundation counseling, spiritual Atlanta STD Clinic (knows as) x Condom distribution, Alliance Family Care My Brother s Keeper X N/A Training and capacity services N/A

65 Page64 Attachment C: Community Engagement Report Intentionally Left Blank

66 Collaborating to Implement High Impact HIV Prevention: Fulton and DeKalb Counties Community Forum Engagement Report A product of HealthHIV s Capacity Building for Health Departments Program October 24,

67 TABLE OF CONTENTS Introduction Community Engagement Community Engagement Phase I...6 Community Forum Day One...6 Community Forum Day Two Strategy Recommendations Next Steps...16 Community Engagement Phase II 17 Strategy Recommendations Part I Strategy Recommendations Part II..23 Next Steps Contributors.. 27 Appendices (A through I)

68 INTRODUCTION This report summarizes a series of community engagement meetings that were focused on the local HIV epidemic and HIV prevention efforts in Fulton and DeKalb Counties, Georgia (Atlanta, GA). The meetings were convened to engage community stakeholders in the identification and prioritization of innovative HIV prevention strategies for the counties to address the high burden of HIV. A two-phase Community Engagement model was utilized. Phase I was a two-day Community Forum held on September 27 and 28, Phase II was a one-day Community Forum held on October 17, As the HIV prevention, care, and treatment landscape evolves and new public health systems are put in place, new strategies and interventions must be recognized and implemented. The National HIV/AIDS Strategy (NHAS), new biomedical approaches, funding redirection, increased accountability, high impact prevention (HIP), healthcare reform, and others, must be incorporated into strategic HIV prevention planning in Fulton and DeKalb Counties. Through a series of meetings, the community was able to come together to assess the local responses to HIV service delivery and outcomes. Georgia is ranked the sixth highest in the nation for its cumulative reported number of AIDS cases through December In 2010, 66% of Georgians living with HIV/AIDS resided in the Atlanta Metropolitan Statistical Area (MSA). The Atlanta MSA had the 13 th highest rate of HIV diagnosis in 2010 with a rate of 30 per 100,000 persons. 2 Within the Atlanta MSA, Fulton and DeKalb Counties had the highest 2010 HIV prevalence rates. 3 The Centers for Disease Control and Prevention (CDC) funded Fulton County Department of Health and Wellness in January 2012 to implement HIV prevention efforts in Atlanta, GA. It was with this in mind that Fulton and DeKalb Counties initiated collaboration with HealthHIV and community stakeholders to develop a new strategic framework and integrated prevention plan for addressing HIV in their community. (See Appendix A for additional 2011 epidemiological data.) The intended outcomes of the community engagement meetings were to: 1. Increase stakeholder understanding of the changing HIV prevention, care, and treatment landscape, including high impact HIV prevention and National HIV/AIDS Strategy. 2. Identify community successes and challenges in implementing HIV prevention strategies. 3. Inform Fulton and DeKalb counties regarding activities, strategies, and programmatic directions in addressing the HIV prevention needs of the community. 4. Recommend community strategies for inclusion in the Fulton and DeKalb Counties HIV prevention jurisdictional and comprehensive plans. 1 CDC, HIV/AIDS Surveillance Report, 2009 (Table 20), reports/2009report/ 2 CDC, HIV/AIDS Surveillance Report, 2010 (Table 23), reports/2010report/ 3 HIV/AIDS Epidemiology Section, Division of Health Protection, Georgia Department of Public Health, Georgia HIV/AIDS Surveillance Summary, Data Through December 31,

69 COMMUNITY ENGAGEMENT In July 2012, after detailed conversations with Fulton County Department of Health and Wellness (FCDHW), HealthHIV developed a community engagement framework to be implemented in order to identify HIV prevention strategies that should be considered for inclusion in the Comprehensive HIV Prevention Program Plan to be submitted to CDC. After initial conversations and meetings in August 2012, the community engagement dates, location, speakers and participants were identified. On September 27 and 28, HealthHIV sponsored the first phase of community engagement meetings, Collaborating to Implement High-Impact HIV Prevention: Fulton and DeKalb Counties Community Forum, titled after FCDHW s High-Impact HIV Prevention Program. The second, and final, phase of the community engagement process was a follow-up meeting held on October 17. The Community Forum goal is to: Engage community stakeholders in the identification and prioritization of innovative HIV prevention strategies for Fulton and DeKalb Counties to address the high burden of HIV in the community. HealthHIV Director of Prevention and Policy, Michael Shankle, MPH, and Prevention and Policy Manager, Marissa Tonelli, served as facilitators for the meetings along with support from Fulton County Department of Health and Wellness staff members. The facilitators sought to engage participants in assessing existing capacity on the community level in the following areas: Strategic Planning: Responding to evolving public health systems Recruitment: Approaches to outreach and early intervention Testing: Efforts to identify and diagnose persons currently infected or at-risk Linkage to care: Referring and ensuring HIV-positive persons are connected to HIV clinical care Treatment Access: Ensuring all HIV-positive persons wanting and needing ART are able to access medication and clinical care Supporting: Innovative efforts in providing HIV programs and support services to a diverse population of HIV-positive persons Retention in care: Retaining HIV-positive persons in care, whether they are on ART or not The Community Forum objectives are to: 1. Inform the community of the jurisdictional planning process and assess interest in the process 2. Identify successes and challenges in addressing the HIV epidemic in Fulton and DeKalb Counties 3. Engage community stakeholders in identifying local strategies for meeting the goals of the National HIV/AIDS Strategy 4

70 4. Engage stakeholders in community driven initiatives to reduce the burden of HIV in Fulton and DeKalb Counties 5. Provide models (high impact prevention, prevention with positives, targeted testing, municipal scale-up, linkage and retention in care) to improve HIV treatment cascade outcomes 6. Provide stakeholders an opportunity to engage in the development of the jurisdictional planning framework and the comprehensive HIV prevention plan 5

71 COMMUNITY ENGAGEMENT PHASE I Community Forum Day One Thursday, September 27, 2012 When arriving on the first day of the Community Forum, participants were asked to write down one word on a note card that described their view of HIV prevention, care, and treatment in Fulton and DeKalb Counties. The responses varied greatly with the most common words being challenging and necessary. Below is the word cloud that was generated from the responses. Figure 1. Participant views of HIV prevention, care, and treatment in Fulton and DeKalb Counties. Sept Marissa Tonelli, HealthHIV Prevention and Policy Manager, welcomed the community stakeholders and introduced Veronica Hartwell, Health Program Administrator, Fulton County Department of Health and Wellness, to provide opening remarks. Veronica Hartwell emphasized the importance of these community engagement meetings, and community input, in the development of the Fulton and DeKalb Counties Jurisdictional HIV Prevention Plan. She then introduced the Director of the DeKalb County Board of Health, Dr. Sandra Elizabeth Ford, who reiterated the significance of the Community Forum and subsequent meetings. Dr. Ford stated that she was eager to hear ideas and feedback from the community and to be able to re-connect with the local level HIV prevention, care, and treatment providers. Michael Shankle, MPH, Director of Prevention and Policy at HealthHIV, concluded the opening remarks by presenting the goals, objectives and intended outcomes of the Community Forum as well as highlighted the necessity to put aside differences and past conflicts to focus on the outcomes. Following the welcoming remarks, participants were asked to identify themselves and announce what they hoped to achieve from the Community Forum meetings. Representation in the room ranged from community-based organizations, community health centers, epidemiologists, state health departments, health educators, consumers, 6

72 and more. (See Appendix B for full list of attendees.) Overwhelmingly, the participants responded that they hoped to achieve increased collaboration and information sharing, decreased duplication, and keep up with the changing HIV prevention landscape. Below is the word cloud that was generated from the responses. (See Appendix C for complete list.) Figure 2. What Community Forum participants hope to achieve throughout the 2-day meeting. Sept Drs. Jane Kelly and Omar Whiteside of the Georgia Department of Public Health (GDPH) Epidemiology Branch presented Fulton and DeKalb Counties epidemiological data to the participants. It is important to note that Fulton County Department of Health and Wellness (FCDHW) was challenged in assembling epidemiological data for the county because most HIV data is housed at the state health department level. FCDHW is currently working with the GDPH Epidemiological Branch to streamline the process for requesting county-level data, and is also developing internal surveillance capacity. Fulton and DeKalb Counties have almost half of the total newly identified HIV cases in the state of Georgia, and 58% of the persons currently living with HIV. Of the newly identified cases in Fulton and DeKalb Counties, over 80% of the epidemic is among males. More than 75% of the epidemic is among Blacks. Epidemiological data from the Georgia State Health Department has significant gaps, with a disproportionate number of HIV cases that have no known risk identified. However, where there is a reported risk category, 94% of newly identified HIV cases are among men who have sex with men (MSM). The majority of newly identified HIV cases are also between the ages of 20 and 49 years. Drs. Kelly and Whiteside pointed out that of those currently living with HIV, and where risk category has been reported, 73% identify as MSM. Of those currently living with HIV, the majority of cases fall between the ages of 30 and 59 years. 4 Trending indicates that the epidemic is becoming younger and increasingly more common among MSM. 4 HIV/AIDS Epidemiology Section, Division of Health Protection, Georgia Department of Public Health, Georgia HIV/AIDS Surveillance Summary, Data Through December 31,