TABLE OF CONTENTS:

Executive Summary ...... Page 3

Problem Description ...... Page 5

Outreach/Prevention Needs ...... Page 6

Surveys, Focus Groups ...... Page 7

Task Team Recommendations ...... Page 13

Systems Barriers & Recommended Strategies ...... Page 19

Conclusions ...... Page 20

Appendix A: Executive Advisory Board Members

Project Staff ...... Page 23

Appendix B: Summary of Performance Outcomes...... Page 24

HIV/SA/MI INTEGRATION PLANNING PROJECT REPORT

Executive Summary

The HIV/SA/MI Integrated Planning Project was funded by the Substance Abuse/Mental Health Services Administration (SAMHSA) . In October, 2000, the Center for Substance Abuse Treatment issued $900,000 in one-year planning grants to six different communities in the U.S. The target population was racial and ethnic groups who are at the highest risk for substance abuse and HIV, and mental illness including African Americans, Latinos & Asians. This was to allow local and state agencies to:

  • Provide community education
  • Develop community advisory boards
  • Carry out training on organizational and community change dynamics
  • Provide technical assistance
  • Evaluate the community planning process

It was intended that at the end of Phase I, grantees would have:

  • developed a community planning process that integrated and improved the delivery of substance abuse, HIV/AIDS prevention and treatment, mental health, primary care and public health services.
  • developed priorities and plans for improving these services and plans that will reduce the risk of HIV transmission
  • decided how decisions would need to be made and conflicts resolved (governance)
  • focused its planning efforts on services for: African Americans, Latinos and Asians.
  • applied for implementation grants from SAMHSA in May, 2001

Results:

Utilizing this grant, the Mecklenburg County Health Department led a year-long planning process to formulate a plan to address this integration challenge within Mecklenburg County. An Executive Advisory Board was formed, made up of over 25 collaborators which included providers, consumers and advocates. This board developed the following mission statement:

"We will analyze three continuums of services and their interactions with minority

patients and their caregivers. The target population includes individuals who have

or are at risk of developing HIV/AIDS with substance abuse and/or mental illness.

Key stakeholders will be involved in developing a system which minimizes barriers

to coordinated services."

Planning Process:

In October, 2000, when the Board began to establish a baseline for the needs assessment, the Evaluator identified the following information gaps which would impede needs assessment: Persons with or at-risk of HIV could not be identified if they had not accessed Mecklenburg County Health Department (MCHD) or other provider services. This would include numerous foreign-born (a growing demographic in Mecklenburg County) and/or minority populations that do not access or have no access to services, especially in rural areas. Hence, service delivery/access to information would be limitedto existing consumers who were already accessing the system of care. Geographically andculturally diverse outreach activities were needed to determine the potential need for education/prevention services in Mecklenburg County.

Overall, the existing data was limited because we did not know anything about those with HIV/AIDS who had not accessed services. CDC data and the Health Department data suggest, however, that HIV is typically under-tested and underreported. Information available on access to services and knowledge about services was limited to those who were already "consumers" and had already accessed services.

In order to broaden insight into the needs for coordinated services and the best way to approach this, the following activities took place during the planning year:

  • Members of the Executive Advisory Board were recruited with the goal in mind that the representation from providers would not exceed that of consumers and advocates in order to have a comfort level for those who were not as accustomed to participating in this type of meeting and to gain as much input from "outside" the system as possible. (See Appendix A).
  • Board meetings were held monthly to gain input and dialogue on what was working well and what could be improved in the effort to provide stronger prevention efforts and continuity of care for those consumers with HIV/substance abuse and mental illness.
  • Two community forums were held in a high-risk area of town under the auspices of the faith community to gather further input into the plan as well as gain feedback on the plan as it developed.
  • Individual interviews and focus groups were held in ethnic communities to gain information on access to services.

Throughout the collaborative planning process, Task Teams (subcommittees of the Board) identified priorities and service gaps and made recommendations to the EAB regarding the following areas of primary concern: (1) Outreach/Prevention; (2) Treatment Integration; and, (3) Cross-training. These recommendations evolved into an Action Plan, which is included in this report.

The three Task Teams designed specific plans in each area with the idea that each plan's implementation would reflect input on cultural accessibility. As a follow up, the Project Evaluator conducted focus groups and surveys with providers and stakeholders to gauge community response to the plan among providers involved in the planning process and others. Some parts of the plan were supported broadly; others less so within the provider community.

Unfortunately, SAMHSA was not able to provide implementation funds as anticipated due to budget constraints. Therefore, implementation will depend on future funding found by stakeholders. In spite of this, some collaborative efforts resulted.

The results of the needs assessment, recommended strategies, the post-planning survey and community response to the process are covered in this report.

Problem Description:

The Mecklenburg County Health Department (MCHD) 1999 figures show that the African-American population is disproportionately affected by HIV/AIDS in this county. African-Americans are less than one-third of the county's total population (648,000) but represent 83% of local 2000 AIDS cases. Locally African-Americans die from AIDS at 9 times the rate for whites. Census estimates on the local Hispanic/Latino population show an increase in population of 677% since 1990. Latinos represent 45% of the local international population of 115,000. The Asian population has increased by 226% during the same time frame and is estimated at 31,000. These populations may be vulnerable to contracting HIV/AIDS due to cultural barriers in accessing prevention and treatment. Development of local culturally sensitive HIV prevention and treatment strategies for these new populations is almost non-existent.

The prevalence of co-occurring illness is becoming commonplace within the HIV/AIDS population. Many AIDS cases are living longer and exposure trends are changing from "men having sex with men" (MSM) to those with chemical dependencies and transmission through injection drug use (IDU) or MSM/IDU. Current literature indicates mental health problems associated with HIV infection are inevitable and those with co-occurring severe and persistent mental illness are disproportionately effected by the AIDS epidemic. One key reason for difficulties in halting the spread of this disease in Mecklenburg is the relative isolation of four different professions of caregivers (HIV case managers, physicians, substance abuse professionals, and mental health professionals) addressing substance abuse, mental illness and AIDS through separate continuums of services.

HIV workers assist the consumer in acquiring financial and other supports to promote survival. Physicians utilize medical technology to address the physical symptoms of the disease. Substance abuse professionals approach treatment within the framework of confronting the consumer on his/her denial of substance abuse problems, frequently discouraging reliance on medications for recovery. Mental health professionals often rely on psychoactive drugs to assist in recovery from depression and stabilization of symptoms of severe and persistent mental illnesses. The informal caregivers, family members and friends, find navigating the systems of care a never-ending exercise in frustration.

Outreach/Prevention Needs

Since service providers do very little identification and tracking of consumers with HIV/AIDS, substance abuse or mental illness, the Project Staff found it difficult to assess numbers of those needing coordinated service delivery/outreach/prevention services. However, providers were asked to estimate the % of current consumers within their systems having HIV+ and substance abuse and/or mental health issues. This following information was gathered:

PROVIDER/TYPE OF SERVICE / ESTIMATES
Mecklenburg County Health Department HIV Case Management / 50% with substance abuse
Area Mental Health Adult Case Management Dual Diagnosis Team (SA/MI) / 50% clients with substance and chronic mental illness problems estimated to have HIV+
Sheriff's Office / 1.47% of 1700 inmates per month are on HIV medications (people are not tested in jail.)
Metrolina AIDS Project - serves HIV+ / 75% + possible MH problems
Hope Haven - serves substance abusers / 25% already identified as HIV+; another 10-15% are infected but not yet diagnosed
Dilworth Recovery Center - serves substance abusers / Intensive Out-Patient Treatment - 4% over past 2 1/2 years
Charlotte Rescue Mission - serves substance abusers / 18% are HIV+
Right Turn of North Carolina - serves substance abusers / 23% are HIV+
CASCADE - Area Mental Health program serving adult pregnant and postpartum women recovering form substance abuse / about 20% identified as HIV + - higher suspected if all were tested
Chemical Dependency Center - serves substance abusers / Not Available
Substance Abuse Services Center (AMH) - serves substance abusers / Not Available

As a part of the Evaluator's Needs Assessment, estimates from providers in general for Substance Abuse and mental health services indicated a 50% portion of the consumer population with HIV/AIDS. A variety of methodologies were used to collect data through informal contacts in minority communities, the MCHD and other providers.

I. Preliminary Exploration:

In November, 2000, a small in-community survey was conducted by Marlonna
Thomas, M.S.W., Project Director and Reggie Singleton, A Male's Place Director, of those minorities not currently receiving services during four different data gathering efforts. The participants for this survey were randomly selected within a zip code area of the city identified as having a high incidence of STD’s. This survey included 17 African-Americans, African-Somolians, Latin Americans and Asians both male and female. These were spontaneous face to face interviews in informal settings such as laundromats, gas stations, restaurants, etc. The interviewers introduced themselves by explaining that the Mecklenburg County Health Department has been provided a funds to help eliminate gaps and barriers in accessing health care systems. They went on to say that what they knew already was that persons without health insurance were less likely to have a usual source of health care, receive preventive health are services and have their health care needs met. In an effort to eliminate or close healthcare gaps/barriers, their help with answering some brief survey questions would be greatly appreciated. They began with general questions about employment, health insurance, cultural issues and then moved to HIV/AIDS, substance abuse and mental health issues.

Results:

Twelve of the 17 interviewed used the emergency room for services due to lack of access to ongoing health care. Most of the respondents avoided Medicaid since too much personal information had to be shared in order to qualify for assistance. The respondents generally viewed health care services as “insensitive” to cultural issues. They also cited long waits, rudeness and hostile and patronizing attitudes as reasons for avoidance.

All interviewees knew HIV/AIDS could be spread through sexual contact and all knew someone who had died from AIDS. All reported they had unprotected sex, were aware of the risk but trusted their partners or their judgement in selecting “safe” partners and did not like condoms. One female reported she was HIV positive but was not receiving any care at that time.

Four declined comment on personal drug use. The rest used marijuana (10), crack (7), alcohol and cigarettes (17) with two being treated for crack and relapsing. All seemed familiar with depression as a mental health issue. Three attributed their drug use to depression. The majority did not know the direct route to access mental health treatment. Ten said they would use the Emergency Room; four, the Health Clinic; and, only three knew they could contact the Area Mental Health Authority directly.

Although the sampling was small, it provides a reasonable “snap shot” of a group of people "outside" main stream services who by their own report have high risk HIV/AIDS behaviors. It also suggests significant barriers related to trust in both native and foreign born communities.

II. Next source: Targeted Minorities:y

Key informant and focus group interviews were conducted in November and December of 2001 to collect data on populations at risk. The populations included:

  • Minority women
  • Men who have sex with men
  • Substance abusers,
  • Hispanics and
  • Asians
  • Individuals with severe and persistent mental illness

A.African-Americans: A major risk group for HIV infection are minority women through their own drug use or heterosexual contact with an HIV + person who is also an IV drug user. The women had generally good relations with case managers and health providers, however, strong social and family supports assisted them in coping emotionally with the illness. T the presence of the illness pointed up systems barriers in other areas such as access to housing and jobs. (For example, people treated with HIV medications test positive for employment drug screens.) Housing barriers existed for women with HIV due to the basic lack of affordable housing and the stigma of HIV/AIDS resulting from revealing income sources.

HIV+ men who have sex with men (MSM) are much more concerned about privacy than HIV+ women and more readily access formal service providers and church support although they seldom share their HIV status with church contacts. Women are less able to maintain jobs, housing and health. It was postulated that this is due to women often being single parents and having additional gynecological healthcare needs.

Both groups saw a need for increased education for their families and communities on HIV/AIDS and the problems living with the illness. African-American churches were seen as a strong potential source of support for outreach and prevention by consumers, providers and other stakeholders. Support groups were seen as being very needed for consumers and family members of consumers. Currently, threesupport groups exist for consumers and/or their families in Charlotte-Mecklenburg. In checking the HIV Consortium services web site listing and Supportworks.org, these groups are listed along with eight others which existed at some point in time but have been discontinued. The three in existence are under the Metrolina AIDS Project.

Interviews with health care providers found that many needed more education about HIV particularly in the mental health area. Substance abuse and HIV workers needed more information about mental illness. There was consensus among the consumers and providers interviewed that cross-training is an important vehicle to improving service delivery.

B. Latinos:

While the rates of HIV infection among Latinos in North Carolina is low, there has also been an increase; between 1995 and 1997 the number of new HIV cases among Hispanics increased from 18 to 29, a 62 percent increase (North Carolina Office of Minority Health and State Office of Health Statistics 1999). This is in due to the fact that Hispanics are the fastest growing minority in NC (Bender 1995). Hispanics are incredibly diverse in terms of culture, but compared to African Americans are less likely to own a home and have lower levels of educational attainment; one in four Hispanic families lives in poverty (Bender 1995).

Language is another major barrier to adequate healthcare for Hispanics (Bender 1995). The lack of sufficient English speaking skills makes it very difficult for Hispanics to obtain information, or to seek out healthcare. Many Hispanics have some limited English speaking skills - referred to as "Survival English." These survival skills are often overestimated by healthcare providers, who assume that the patient can understand complex information about a clinical diagnosis and treatment. Even the use of an interpreter leads to a significant number of omissions and inaccuracies; Woloshin et al. (1995) found that 23 to 52 percent of translator assisted interactions between a healthcare provider and a Hispanic patient were incorrectly translated. Relatively few health care providers are Hispanic; only 4.8 percent of physicians and only 5.8 percent of licensed practical nurses in the U.S. are Hispanic (Kamat 1999). It is not recommended that children and family members serve as translators (Bender 1995).

Hispanic populations are also poorer than the general population, and this constitutes another important barrier to healthcare. In North Carolina Hispanics represent 21 percent of the uninsured population, which is similar to the national level (NC Office of Minority Health and State Center for Health Statistics 1999). While Medicaid is available, it is difficult for a individual with limited English skills or knowledge of the social service system to obtain care. Furthermore, immigrant status disqualifies an individual from receiving Medicaid or other public benefits, and welfare and immigration laws deter ethnic minorities from preventative healthcare (Bau 1997).