Community Needs and the Future of Service Delivery for Latino MSM Living with HIV in the San Francisco EMA SUMMARY REPORT

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1 Cmmunity Needs and the Future f Service Delivery fr Latin MSM Living with HIV in the San Francisc EMA SUMMARY REPORT BACKGROUND AND METHODOLOGY This needs assessment is a united effrt by the Spanish-speaking Immigrant cmmunity, the Latin cmmunity at large, the Latin HIV Service prviders and the SF HIV Health Services Planning Cuncil. The cntent f this dcument ffers cntext and factrs t cnsider regarding the needs f Latin MSM living with HIV. Accrding t the mst recent HIV Epidemilgical Reprt Status f the HIV/AIDS Epidemic in San Francisc, Latin/a PLWHA make up 17% f San Francisc s PLWHA ppulatin (N=15,849). This reprt als nted: Latin/a make up 15% f living HIV cases with histry f jail (N=1,039); 12% were c-infected Hepatitis C; and an estimated 12% were nt receiving care. In regards t San Mate and Marin, the Epi Reprt nted that 25% f PLWHA are Latin/a in San Mate and 15.6% in Marin. Accrding t the mst recent ARIES Reprt An Analysis f San Francisc Eligible Metrplitan Area Ryan White Part A & B Fr the Cntract Perid, Latin/a PLWH make up 21% f San Francisc s PLWH ppulatin, 20.5% in Marin, and 39.3% in San Mate. This reprt als nted that Latin/a make up 22.8% f Male PLWH, 22.2% f Female PLWH, and 31.9% f Transgender PLWH; 20.1% f New Clients (N=890); 15.5% f Clients Wh Have Died (N=70); 61.8% lived at r belw the Pverty Line; 65.3% f Latin/a HIV Expsure was frm MSM cntact; 34.3% had a CDC-Defined AIDS and 22.9% had a diagnsis f Disabling AIDS ; 73.4% were currently n HAART; 51.5% has a Viral Lad f less than 50 and 27.4% were between The Latin ppulatin is currently cnsidered a targeted demgraphic within the San Francisc EMA HIV Health Services Planning Cuncil s Special Ppulatins Definitin: Special Ppulatins The Cuncil recgnizes special ppulatins which have unique r disprprtinate barriers t care. They need additinal r unique services, r require a special level f expertise t maintain them in care. The fllwing ppulatins were identified, based n the data that has been presented t the Cuncil: Cmmunities with linguistic r cultural barriers t care. The Cuncil includes undcumented individuals in this categry, as well as mnlingual Spanish speakers. 1 P a g e

2 In 2011, the Cnsumer & Minrity Affairs (CMA) Cmmittee f the San Francisc EMA HIV Health Services Planning Cuncil (HHSPC) discussed ptential target ppulatins fr the Needs Assessment. Factrs fr chsing a target ppulatin included target ppulatins nted within the HHSPC s Three-Year Cmprehensive Plan, HIV disease burden within targeted ppulatins, and amunt f time since a targeted ppulatin has received a needs assessment. After deliberating n the tpic ver the curse f tw meetings, CMA determined that the HHSPC Needs Assessment wuld target the Latin MSM ppulatin. In March 2012, HHSPC Staff initiated the frmatin f the Latin MSM Needs Assessment Wrk Grup (LMNA Wrk Grup) by inviting a range f stakehlders, including prviders and cnsumers f services assciated with the fllwing agencies: Clinica Esperanza, Missin Neighbrhd Health Center Clinica Salud, San Francisc General Hspital Ward 86 Edisn Clinic, San Mate DPH Cmmunity Clinic El Ambiente, Aguilas Institut Familiar de la Raza Marin AIDS Prject San Francisc EMA HIV Health Services Planning Cuncil At the first meeting, the grup decided t meet n a mnthly basis, t perate by cnsensus, and t avid the use f frmal parliamentary prcedure in rder t better encurage participatin by all f its members. At its secnd meeting, the LMNA Wrk Grup elected its C-Chairs: Jrge Zepeda, San Francisc AIDS Fundatin and Enrique Asis, HHSPC Staff. Discussin during that meeting and subsequent meetings determined that the LMNA Wrk Grup wuld implement a series f fcus grups: six t take place in San Francisc in the latter half f 2012 and ne each in Marin and San Mate in the first quarter f The grup als determined: Fcus grups wuld take place in English and in Spanish Fcus grups wuld take place in HIV service lcatins familiar t clients in rder t better utreach t and recruit participants. Outreach als tk place during cmmunity meetings fr the Latin HIV+ psitive; Structure f fcus grups (described belw); Members f the LMNA Wrk Grup will als functin as facilitatrs and nte-takers fr the fcus grups. Attendance at a facilitatr training (described belw) was cnsidered mandatry fr all ptential fcus grup facilitatrs; Attendance at fcus grups wuld be incentivized (thrugh $30 gift certificates t Safeway and Walgreen s); lunch r dinner wuld als be prvided. 2 P a g e

3 Fcus Grup Structure 1) General facilitatin and attendant interactin guidelines 2) Annymus survey/questinnaire 3) Explanatin f rle and functins f HHSPC 4) Facilitated Discussin regarding utilizatin f services, access t services, barriers t care, and challenges/limitatins in HIV service utilizatin 5) Descriptin f Ryan White Part A HIV service categries 6) Service priritizatin dt exercise 7) Participant evaluatin f fcus grup sessin Additinally, the LMNA Wrk Grup created facilitatr scripts in bth English and Spanish t supprt facilitatrs during fcus grups. The CMA Cmmittee reviewed and apprved the Latin MSM Needs Assessment recruitment plan, fcus grup structure, facilitatr scripts, and fcus grup dates and lcatins. Facilitatr & Nte-Taker Training As nted abve, the LMNA Wrk Grup determined that attendance at tw-hur was mandatry fr all facilitatrs and nte-takers. Cuncil Staff implemented this training, which included an verview f infrmatin cllectin methdlgy, demgraphics data input, HRSA directives regarding participant cnfidentiality, an verview f the dt exercise, and a review f relevant HRSA service categries. 66 attendees participated in the six fcus grups taking place in San Francisc 9 attendees participated in the San Mate fcus grup 9 attendees participated in the Marin fcus grup 84 questinnaires were cmpleted by fcus grup participants FINDINGS Priritizatin Exercise Results 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% 3 P a g e

4 1. Immigratin, Pverty & Language Barriers Immigratin The HIV+ Latin MSM ppulatin in the SF EMA includes many Spanish-speaking immigrants. Only a small prtin f this grup were brn in the US, with a majrity immigrating frm Mexic and ther Latin American cuntries. Only 9.6% f the Latin MSM needs assessment participants were brn in the US. Over 90% f needs assessment participants were immigrants. The majrity (50.6%) f immigrants that participated in the fcus grups are frm Mexic. The next largest grups were immigrants frm El Salvadr (10%), Guatemala (7.2%), and ther Latin American cuntries including Nicaragua, Peru & Cuba. The next largest grups were immigrants frm El Salvadr (10%), Guatemala (7.2%), and ther Latin American cuntries including Nicaragua, Peru & Cuba. These neighbring cuntries (Mexic, Guatemala, & El Salvadr) have a histry f transient immigratin Participants nted challenges with integrating within American culture and finding their sense f belnging. Pverty Cmparing the data with ther specific grups in previus Needs Assessments (aging, transgender), the majrity f Latin MSM wh participated in the needs assessment demnstrate the lwest level f pverty. Clse t 90% f participants reprt having either nly enugh mney t survive r nt enugh mney t live n. Over 73% f participants reprted an annual incme f less than $10,000 (fr reference: Ryan White eligibility defines lw incme as an annual incme equal t r less than 400% f the Federal Pverty Level, which fr 2013 is $45,960 fr ne persn) Native Spanish-speaking immigrants Less than a quarter f participants reprted being fluent in English, with nearly 15% reprting that they didn t understand r speak English Less than 10% f participants were brn in the US. A New Dimensin f Severe Need The fcus grup participants are a special ppulatin that encunter cumulative barriers n several different levels: severe pverty, linguistic challenges, cultural difference, and issues arund legal status barriers. This creates a series f systematic and structural barriers and challenges. 4 P a g e

5 2. Hmelessness & Financial Hardship Hmelessness Mre than 40% f participants reprted having been hmeless r marginally hused at sme pint in the US. Of this grup, ver 28% reprted being hmeless r marginally hused within the last year. Husing was the number ne pririty in each fcus grup. Financial Hardship Over 45% f participants reprted relying n Disability (26.2%) r General Assistance (19%) as their primary surce f incme. Mre than 40% reprted nt having enugh mney t live n. Less than a quarter f participants have a steady emplyment situatin. Mre than 50% f participants receive between 0 and $500/mnth including all f their surces f incme. 3. The Immigrant Experience in the SF EMA System f Care Each fcus grup included participants wh expressed cncerns abut the final implementatin f the Affrdable Care Act in that it des nt cver undcumented residents. Service Pints f Entry and Eligibility were cnsidered cnfusing r unknwn fr sme fcus grup participants. Fcus grup participants were ften reticent t discuss barriers and challenges t care instead expressing feelings f gratitude, appreciatin, and even guilt at the services they receive. Many fcus grup participants frm Marin and San Mate Cunties were unaware f legal and supprt services fr which they are eligible. The challenges and language limitatins f this immigrant grup plus HIV stigma aggravate an extreme situatin f cultural and scial islatin. 4. Nn-Medical Service Needs Husing was the number ne pririty in the service categries priritizatin exercise within each f the 8 fcus grups. Husing, Dental, Medicatins and Fd are the fur tp pririties fr all fcus grups during the aggregated priritizatin exercise. The priritizatin exercise, as well as cnsistent cmments within all fcus grups, indicate a clear need fr nn-medical supprt services. All data abut services pririties illustrates the imprtance f evaluating the San Francisc Mdel f Care and its utcmes as a cntinuum, with significant strides t be made twards addressing the scial and ecnmic determinants f health including pverty, hmelessness, and the unique linguistic and cultural challenges faced by Latin immigrants in the US. 5 P a g e

6 5. A Unique Cascade Overall, Latin MSM surveyed in this needs assessment demnstrated strnger health utcmes than thse reprted bth lcally and n a natinal level within the Gardner Cascade. Fr example, regarding viral suppressin: 95% f fcus grup participants self-reprted an undetected viral lad vs. 50% (San Francisc verall) vs. 19% (natinal). 100% f participants in Latin MSM fcus grups self-reprted taking HIV medicatin. Many f the fcus grup participants are lng term survivrs with high levels f adherence and a lng histry f medical treatment. Over 95% f participants reprted a great success f having achieved an undetectable viral lad. While the high rates f viral suppressin and treatment adherence indicate psitive health utcmes, these utcmes exist within a setting f severe indigence, indicating a set f clearly unmet needs. QUOTES FROM PARTICIPANTS Se cnvierte en alg facil cumplir cn tu tratamient (tmar ls medicaments) cuand tienes casa y cmida, pr l que n pued decir que es mas imprtante. It becmes easy t cmply with yur treatment (take yur medicatins) when yu have a hme and fd, because I can t say what is mre imprtant. La dificultad de ls prgramas de vivienda, sn cmplejs de pr si y para ls latins se cnvierten de una pesadilla trmentsa. The difficulty f the husing prgrams are cmplex and fr Latins they becme a turbulent nightmare. Las listas de espera sn tan largas Hay ds tips de clientes: ls que entrarn en el Sistema cuand habia casas y ls que en ls ultims anis ns pusiern en listas de espera. The wait lists are s lng there are tw types f clients: thse that entered the system when there were huses and thse in the last cuple years that have t wait n the wait list. Creia que exageraban cuand escuchaba que se quejaban de ls dentistas hasta que me tc a mi I thught that they were exaggerating when I heard them cmplain abut the dentists. Until they gt their hands n me. Tener dnde cmer y que te atiendan, es una de las raznes pr las que me vine de San Antni TX, para SF. T have smewhere t eat and where they understand yu, it s ne f the reasns why I left San Antni fr San Francisc. Cuand Sali de la carcel, estuve dand vuelta pr ls shelters pr casi un ani. When I left jail, I was back and frth between shelters fr almst a year. 6 P a g e

7 Aunque tenia mi residencia en transicin me trataban cm si fuera illegal. Even thugh I had my transitinal residency, they treated me like I was an illegal immigrant. El asil plitic pr rientacin sexual me ayud muchisim y me devlvi la esperanza.deje de pensar que me iva a mrir prnt. Plitical asylum fr sexual rientatin helped me a lt and gave me hpe. I stpped thinking that I was ging t die sn. Ls servicis legales de imigracin sn muy imprtantes pr primera vez vi que me trataban cn dignidad The immigratin legal services are very imprtant. Fr the first time I saw that they treated me with dignity. El tema de tener cancer y sida, hace mas cmplicada la situacin, y tus psibilidades de pedir ayuda. The idea f having cancer and AIDS makes yur situatin and the pssibility f finding help mre cmplicated. N tds ls case management y trabajadres sciales tienen la misma infrmacin y cmpetencia. Nt all f the case managers and scial wrkers have the same infrmatin and cmpetency. El primer an sl sbrevivi prque cmia gratis en ls grups de apy. The first year I nly survived because I ate the free fd in the supprt grups. Me aterrrizaba ir a las agencias pr mied a que nadie me entendiera. Cuand n te puedes cmunicar en tu idima es cm si desaparecieras. I was terrified t g t the agencies fr fear that n ne wuld understand me. When yu can t cmmunicate in yur wn language it s like yu disappear. El dmini del idima es una de las barrera mas imprtantes, es much mas que entender l que te dicen es entender cm funcinan ls servicis y quien te puede y quien NO te puede ayudar. Cmmand f the language is ne f the mst imprtant barriers, it s much mre than understanding what they say t yu, it s understanding hw the services functin and wh can and can t help yu. 7 P a g e

8 CONCLUSIONS 1. Due t the large number f Latin MSM living with HIV/AIDS in San Francisc, as well as the disprprtinate level f sciecnmic, cultural, and linguistic challenges that this cmmunity faces, reducing barriers t care fr Latin MSM is a critical cmpnent f successfully meeting the needs f this ppulatin. Prviding services in Spanish and bridging language barriers are essential fr addressing the needs f this ppulatin. Addressing Latin immigrants cultural and scial differences is an imprtant element t reduce islatin. 2. Planning fr prgrams culturally and scially sensitive prgrams fr Latin MSM living with HIV/AIDS shuld cnsider the stark funding envirnment and lk at the develpment f innvative and cllabrative prgrams that are cst effective and ideally cst neutral. There are several types f rganizatins, including immigratin, husing, and medical services, that already prvide imprtant services fr this ppulatin. An increased level f cmmunicatin and cllabratin between these rganizatins culd address hw t better and mre effectively serve this target ppulatin. 3. Despite significant barriers and challenges, the self-reprted high level f adherence and viral suppressin by fcus grup participants suggests that the San Francisc Mdel f Care is wrking t engage and retain thse fcus grup participants in care. Hwever, many fcus grup participants nted that late diagnsis is still a challenge. 4. Althugh the self-reprted high rates f treatment adherence and viral suppressin are indicatrs f success, there is als a high level f severe pverty in this ppulatin. Once in care, fcus grup participants cntinued t be engaged in care. A challenge is t develp preventin and early engagement befre an HIV diagnsis r t quickly identify recently infected Latin immigrant MSM and bring them int care. When cmbining a prpensity twards indigence with additinal linguistic challenges and issues with legal status, the fllwing becmes clear: It is imprtant t measure nn-clinical health indicatrs in rder t better address sciecnmic barriers t wellness. Supprt Services prviders must be equal partners with medical prviders in rder t ensure quality supprt in additin t quality medical care. 5. As we mve int an era f healthcare refrm, it is crucial t ensure that this ppulatin des nt fall thrugh the cracks r that services are nt disrupted due t changing funding surces and eligibility criteria. The HIV+ Latin MSM cmmunity faces issues that nt nly cnstitute barriers t care, but als barriers t vice and representatin. ACA changes have the ptential t disprprtinately affect this cmmunity, and it is imprtant that the SF EMA HHSPC build in additinal cnsideratins t preserve Latin MSM access t care and services. 8 P a g e

9 Althugh this needs assessment illustrates many f the successes f implementing a system f care that is accessible t HIV+ Latin MSM, it is essential fr Latin MSM t be able t successfully navigate the many unknwns and the cmplexity f the San Francisc EMA s changing landscape in rder t enjy better health and a sustainable quality f life. THANK YOU AGUILAS Eric Arguell Juan Ramn Davila Carls Mrales COMMUNITY Octavi Feregrin Manuel Banuels David Arauj Anthng Castr Juan P Martinez Albert Sanchez Gerard Carmna Cuncil Staff Ali Cne SFDPH Celinda Cantu Marie Kay Parisi Kevin Hutchkrft HHSPC CM Maritza Penags CM Gabriel Ortega Institut Familiar de la Raza Armand Hernandez Jse Luis Martinez Marin Cunty CM Cecily Emersn Jennifer Malln Andy Fine Maria Camach Sara Grssi MNHC Shaddai Martinez Cuesta Michaela Hffman Vidal Antni Prject Infrm Anne Dnelly San Mate Cunty CM Matt Geltmaker Chris Thibdeaux. Victria Valencia SFAF Jrge Zepeda SF General Hspital Ward 86 Hernan Luduena Segre Dr Annie Lukermeyer Dr. Brad Hare CM Mary Lawrence Hicks 9 P a g e

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