State of Florida Integrated HIV Prevention and Care Plan, including the Statewide Coordinated Statement of Need, CY

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1 State of Florida Integrated HIV Prevention and Care Plan, including the Statewide Coordinated Statement of Need, CY Prepared by The Florida Department of Health, HIV/AIDS Section The AIDS Institute DRAFT Integrated HIV Prevention and Patient Care Plan 1

2 Executive Summary The impact of HIV/AIDS in Florida is far reaching with approximately 110,000 persons living with HIV disease through Every county of Florida s 67 counties had at least six people living with HIV disease through Furthermore, according to the Centers for Disease Control and Prevention (CDC) 2014 HIV Surveillance Report, Florida ranked second among states in the number of cases of HIV infection diagnosed in Similarly, Florida ranked second among states in the rate of HIV infections per 100,000 persons (26.9 per 100,000). Although Florida ranked first among states in the estimated number of AIDS cases diagnosed in 2014, the number of AIDS cases diagnosed from 2005 to 2014 has declined considerably representing a 47% decrease over a 10 year period. This underscores the importance of HIV prevention and care service delivery in Florida. The AIDS Institute and the Florida Department of Health (FDOH), HIV/AIDS Section (HAS) in collaboration with community-based organizations (CBOs) provided information in response to the Centers for Disease Control and Prevention (CDC) and the Health Resources and Services Administration (HRSA) s Integrated HIV Prevention and Care Plan, including the Statewide Coordinated Statement of Need (SCSN). Section I: Statewide Coordinated Statement of Need/Needs Assessment o A. Epidemiologic Overview o B. HIV Care Continuum o C. Financial and Human Resources Inventory o D. Assessing Needs, Gaps and Barriers o E. Data: Access, Sources and Systems Section II: Integrated HIV Prevention and Care Plan o A. Integrated HIV and Prevention and Care Plan o B. Collaborations, Partnerships, and Stakeholder Involvement o C. People Living With HIV (PLWH) and Community Engagement Section III: Monitoring and Improvement DRAFT Integrated HIV Prevention and Patient Care Plan 2

3 Section I: Statewide Coordinated Statement of Need/Needs Assessment A. Epidemiologic Overview Introduction The Florida Department of Health (FDOH), Bureau of Communicable Diseases, HIV/AIDS Section collects, analyzes, and disseminates surveillance data on HIV infection. These surveillance data are one of the primary sources of information on HIV and AIDS in Florida. For instance, HIV and AIDS surveillance data are used by the FDOH s public health partners in other health departments, federal agencies, nonprofit organizations, academic institutions, and the general public to help focus prevention efforts, plan services, allocate resources and monitor trends in HIV infection. This section of the Statewide Coordinated Statement of Need/Needs Assessment summarizes information about HIV infection cases and HIV infection cases classified as AIDS in Florida. Section Organization Florida s epidemiologic overview is organized into 27 subsections: 1. Interpretation of HIV/AIDS Data 2. Florida s Rank in the United States 3. HIV Infection Case Rates by County of Residence 4. AIDS Case Rates by County of Residence 5. Ten Year Trend of HIV Infection Cases by Year of Diagnosis 6. Ten Year Trend of AIDS Cases by Year of Diagnosis 7. Adult HIV Infection and AIDS Cases by Sex 8. Ten Year Trend of Adult HIV Cases by Sex 9. Adult HIV Infection and AIDS Cases by Age 10. Ten Year Trend of HIV Infection Cases by Age Group at Diagnosis and Year of Diagnosis 11. Ten Year Trend of AIDS Cases by Age Group at Diagnosis and Year of Diagnosis 12. Adult HIV Infection Cases, AIDS Cases, and Population Data by Race/Ethnicity 13. Ten Year Trend of Adult HIV Infection Cases by Race/Ethnicity 14. Ten Year Trend of Adult AIDS Cases by Race/Ethnicity 15. Adult HIV Infection Case Rates by Sex and Race/Ethnicity 16. Adult Male HIV Infection and AIDS Cases by Mode of Exposure 17. Adult Female HIV Infection and AIDS Cases by Mode of Exposure 18. Ten Year Trend of Adult Male HIV Infection Cases by Mode of Exposure 19. Ten Year Trend of Adult Female HIV Infection Cases by Mode of Exposure 20. Ten Year Trend of Adult Male AIDS Cases by Mode of Exposure 21. Ten Year Trend of Adult Female AIDS Cases by Mode of Exposure 22. Perinatal HIV/AIDS Cases 23. Prevalence Estimate of HIV Disease in the U.S. and Florida 24. Persons Living with HIV Disease by County of Residence 25. Impact of HIV-Related Deaths 26. Prevention of HIV Disease in Florida 27. Co-morbidity Data DRAFT Integrated HIV Prevention and Patient Care Plan 3

4 1. Interpretation of HIV/AIDS Data All HIV/AIDS data are current as of December 31, HIV infection reporting represents newly diagnosed HIV cases, regardless of AIDS status at time of diagnosis. HIV infection cases and AIDS cases by year of diagnosis are NOT mutually exclusive and CANNOT be added together. Frozen databases of year-end data are generated at the end of each calendar year. These are the same data used for Florida Community Health Assessment Resource Tool Set (CHARTS) and all grant-related data where annual data are included. HIV prevalence data are generated later in the year, usually in July, when most of the estimated death data are complete. Adult cases represent ages 13 and older, pediatric cases are those younger than the age of 13. For data by year, the age is by age at diagnosis. For living data, the age is by current age at the end of the most recent calendar year, regardless of age at diagnosis. Unless otherwise noted, race/ethnicity reference to white residents and black residents represent persons who are white non-hispanic and black non-hispanic, respectively. Also, all references to Hispanic for race/ethnicity represent persons of Hispanic heritage regardless of race. Total statewide data will include Department of Correction Cases (DOC) unless otherwise noted. County data will exclude DOC cases. HIV incidence estimates are approximations of the numbers of people who are newly infected, which include those whose infection has not yet been diagnosed or diagnosed. HIV/AIDS Exposure Mode Categories are as follows: MSM = Men who have sex with men or male-to-male sexual contact with person with HIV/AIDS or known HIV risk IDU = Injection Drug User MSM/IDU = Men who have sex with men or male to male sexual contact and injection drug user Heterosexual = Heterosexual contact with person with HIV/AIDS or known HIV risk Other = Includes hemophilia, transfusion, perinatal, other pediatric risks and other confirmed risks NIR = Cases diagnosed with No Identified Risk Redistribution of NIRs = This illustrated the effect of statistically assigning (redistributing) the NIRs to recognize exposure (risk) categorized by applying the proportions of historically reclassified NIRs to the unresolved NIRs. 2. Florida s Rank in the United States According to the Centers for Disease Control and Prevention (CDC), Florida ranked second among states in the number of cases of Human Immunodeficiency Virus (HIV) DRAFT Integrated HIV Prevention and Patient Care Plan 4

5 infection diagnosed in 2014 (which is the most recent year data are available nationally) (CDC, 2015d).. That year, a total of 5,551 (13% of the U.S. total) HIV Infection cases were diagnosed in California, followed by 5,347 (12%) in Florida and 4,833 (11%) in Texas (Table 1). Additionally, Florida ranked second among states in the rate of HIV infections per 100,000 population. That year, Florida (26.9 per 100,000) was ranked behind Louisiana (30.4). Table 1. Top States in the Number of HIV Infection Cases, and Rates per 100,000 in 2014 Ranking State No. of cases % of US Total Ranking State Rate per 100,000 1 California 5,551 13% 1 Louisiana Florida 5,347 12% 2 Florida Texas 4,833 11% 3 Maryland New York 3,825 9% 4 Georgia Georgia 2,253 5% 5 New York 19.4 Source: CDC. (2015). HIV Surveillance Report, 2014; vol. 26. Florida ranked first among states in the estimated number of acquired immune deficiency syndrome (AIDS) cases diagnosed in 2014 (CDC, 2015d).. That year, a total of 2,578 (12% of the U.S. total) AIDS cases were diagnosed in Florida, followed by 2,263 (11%) in Texas and 2,219 (11%) in California. With regard to the rate of AIDS cases per 100,000 population, Florida (13 per 100,000) ranked second, behind Louisiana (13.7) (Table 2). Table 2. Top States in the Number of AIDS Cases, and Rates per 100,000 in 2014 Ranking State No. of cases % of US Total Ranking State Rate per 100,000 1 Florida 2,578 12% 1 Louisiana Texas 2,263 11% 2 Florida California 2,219 11% 3 Maryland New York 1,919 9% 4 Georgia Georgia 1,137 5% 5 Mississippi 10.6 Source: CDC. (2015). HIV Surveillance Report, 2014; vol. 26. DRAFT Integrated HIV Prevention and Patient Care Plan 5

6 3. HIV Infection Case Rates by County of Residence In 2014, at least one HIV Infection case was diagnosed in all but six counties in Florida. Seven counties diagnosed 100 or more cases (Figure 1). These seven counties included Broward, Duval, Hillsborough, Miami-Dade, Orange, Palm Beach, and Pinellas. These aforementioned counties diagnosed a combined total of 3,380 cases, or 73% of Florida s total diagnosed cases in 2014 (N=4,613). The greatest numbers of HIV cases were diagnosed from Miami-Dade (n=1,198), Broward (n=694), Orange (n=382), and Hillsborough (n=340). These four counties diagnosed a combined total of 2,614 cases in 2014, or nearly three-fifth (57%) of the statewide total. Figure 1. HIV Infection Case Rates* by County of Residence,** Diagnosed in 2014, Florida 62 5 Statewide Data: N= 4,613 State Rate = 23.6 Rate per 100,000 population to to > *Population data were provided by Florida CHARTS as of 7/9/2015. **County totals exclude Department of Corrections cases (N=87). Numbers on counties are cases diagnosed. DRAFT Integrated HIV Prevention and Patient Care Plan 6

7 4. AIDS Case Rates by County of Residence In 2014, at least one AIDS case was diagnosed in all but nine counties in Florida (Figure 2). Although the AIDS epidemic is widespread throughout Florida, the majority of cases were diagnosed from seven counties: Broward, Duval, Hillsborough, Miami- Dade, Orange, Palm Beach, and Pinellas, all reporting over 100 cases in These seven counties diagnosed a combined total of 1,644 cases, or 69% of Florida s total diagnosed cases in 2014 (N=2,370). The greatest numbers of AIDS cases were diagnosed from two counties located in the southeastern part of the state, Broward (n=322) and Miami-Dade (n=444). These two counties diagnosed a combined total of 766 cases in 2014, 32% of the statewide total. Figure 2. AIDS Case Rates* by County of Residence,** Diagnosed in 2014, Florida 21 2 Statewide Data: N=2,370 State Rate = 12.1 Rate per 100,000 Population to to 30.0 > *Population data provided by Florida CHARTS as of 7/9/2015. **County totals exclude Department of Corrections cases (N=45). Numbers on counties are cases diagnosed. DRAFT Integrated HIV Prevention and Patient Care Plan 7

8 Number of Cases Number of Cases 5. Ten Year Trend of HIV Infection Cases by Year of Diagnosis Enhanced laboratory reporting (ELR) laws in 2006 and the expansion of ELR in 2007 led to an artificial peak in newly diagnosed cases of HIV infection in This was followed by a general decline in diagnosed cases through A 4% increase was observed in 2014 compared to the previous year (Figure 3). Figure 3. HIV Infection Cases, by Year of Diagnosis, , Florida 7,000 6,000 5,000 4,000 3,000 2,000 1,000 6,028 5,681 6,512 6,086 5,210 4,719 4,680 4,521 4,433 4, Year of Diagnosis 6. Ten Year Trend of AIDS Cases by Year of Diagnosis As was observed with HIV infection cases, enhanced laboratory reporting (ELR) laws in 2006 and the expansion of ELR in 2007 led to an artificial peak in newly diagnosed cases of AIDS in This was followed by a general decline in diagnosed cases through Another surge in the expansion of ELR in 2012 was followed by another increase in newly diagnosed cases of AIDS in AIDS cases in 2014 dropped by 20% from the previous year (Figure 4). Figure 4. AIDS Cases, by Year of Diagnosis, , Florida 5,000 4,450 4,500 4,238 4,043 4,184 4,000 3,864 3,500 3,157 3,000 3,029 2,855 2,964 2,500 2,370 2,000 1,500 1, Year of Diagnosis DRAFT Integrated HIV Prevention and Patient Care Plan 8

9 7. Adult HIV Infection and AIDS Cases by Sex In 2014, a total of 3,602 adult males and 997 adult females were diagnosed with HIV infection, representing 78% and 22% of cases, respectively (Figure 5). Also, in 2014 a total of 1,694 adult males and 668 adult females were diagnosed with AIDS, representing 72% and 28% of cases, respectively. Figure 5. Percent of Adult HIV Infection and AIDS Cases by Sex, Diagnosed in 2014, Florida HIV Infection N=4,599 AIDS N=2,362 22% 28% Male Female 78% 72% 8. Ten Year Trend of Adult HIV Cases by Sex In 2014, 78% of the adult HIV infection cases were male, compared to 70% in 2005 (Figure 6). Over the past ten years, the proportion of HIV infection cases among men has increased while the proportion among women has decreased. The result is an increase in the male-to-female ratio, from 2.4:1 in 2005 to 3.6:1 in The relative increase in male HIV cases might be attributed to proportional increases in HIV transmission among men who have sex with men (MSM). DRAFT Integrated HIV Prevention and Patient Care Plan 9

10 Percent of Cases Percent of Cases Percent of Cases Figure 6. Percent of Adult HIV Infection Cases, by Sex and Year of Diagnosis, , Florida 100 Male Female M:F Ratio : : Year of Diagnosis 9. Adult HIV Infection and AIDS Cases by Age HIV infection cases tend to be younger than AIDS cases. A greater proportion of HIV infection cases diagnosed in 2014 were among those aged (31%), followed by those aged (23%) (Figure 7). Conversely, the greatest proportion of AIDS cases diagnosed in 2014 were among persons aged 50 or older (34%), followed by those in the age group (26%). Adult cases for both HIV and AIDS are defined as those occurring in people 13 years of age or older. The analysis shown below includes only adult cases. Figure 7. Age Distribution of Florida s Adult HIV Infection Cases Compared with the Age Distribution of Florida s Adult AIDS Cases, Diagnosed in 2014, Florida HIV Infection N=4, AIDS N=2, Age Group Age Group DRAFT Integrated HIV Prevention and Patient Care Plan 10

11 Proportion of Cases 10. Ten Year Trend of HIV Infection Cases by Age Group at Diagnosis and Year of Diagnosis Over the past ten years, the proportion of newly diagnosed adult HIV cases has shown increases for both the (11 percentage points) and 50+ (3 percentage points) age groups. In contrast, the proportion of newly diagnosed adult HIV cases among those in the and age groups decreased by 5 and 11 percentage points respectively, over the same time period (Figure 8). Figure 8. Adult HIV Infection Cases, by Age Group at Diagnosis, and Year of Diagnosis, , Florida Year of Diagnosis 11. Ten Year Trend of AIDS Cases by Age Group at Diagnosis and Year of Diagnosis Over the past ten years, the proportion of newly diagnosed AIDS cases have shown increases for both the and 50+ age groups. The age group increased by 6 percentage points and the 50+ age group increased by 12 percentage points over the past ten years. In contrast, the age group decreased by 5 percentage points and the age group decreased by 12 percentage points over the past ten years. The age group remained relatively level throughout the years. 12. Adult HIV Infection Cases, AIDS Cases, and Population Data by Race/Ethnicity Blacks comprise only 14% of the adult population in Florida, but represent 44% of adult HIV infection cases and 51% of adult AIDS cases diagnosed in 2014 (Figure 9). Similarly, Hispanics comprise 23% of Florida s adult population, and account for 28% of the HIV infection cases and 21% of the AIDS cases. DRAFT Integrated HIV Prevention and Patient Care Plan 11

12 Percent of Cases Figure 9. Adult HIV Infection Cases, AIDS Cases and Population Data, by Race/Ethnicity, Diagnosed in 2014, Florida 28% HIV N=4,599 2% 2014 Florida* Population Estimates N=16,623,794 4% 23% 21% AIDS N=2,362 3% 26% 25% 14% 59% 44% 51% White Black Hispanic Other** *Source: Population estimates are provided by Florida CHARTS as of 7/9/2015. **Other includes Asian/Pacific Islanders, Native Alaskans/American Indians and multi-racial individuals. 13. Ten Year Trend of Adult HIV Infection Cases by Race/Ethnicity From 2005 to 2014, the proportion of adult HIV cases among whites and blacks decreased by 2 and 5 percentage points, respectively (Figure 10). In contrast, increases were observed among Hispanic (7 percentage points) HIV infection cases over this same time period. Figure 10. Percent of Adult HIV Infection Cases, by Race/Ethnicity and Year of Diagnosis, , Florida White Black Hispanic Other* Year of Diagnosis *Other includes American Indian/Alaska Native, Asian/Pacific Islander, and multi-racial individuals. DRAFT Integrated HIV Prevention and Patient Care Plan 12

13 Rate per 100,000 Population 14. Ten Year Trend of Adult AIDS Cases by Race/Ethnicity Of the adult AIDS cases diagnosed in 2014, 25% were white, compared to 51% black, 21% Hispanic and 3% other race/ethnicity. Over the past ten years, the proportion of AIDS cases has remained fairly level among all race/ethnic groups. However, during the same time period, blacks account for over 50% of diagnosed AIDS cases each year. 15. Adult HIV Infection Case Rates by Sex and Race/Ethnicity Black men and, to an even greater extent, black women are over-represented in the HIV epidemic (Figure 11). The HIV case rate for 2014 is nearly six times higher among black men than among white men. Among black women, the HIV case rate is nearly 14-fold greater than among white women. Hispanic male and Hispanic female HIV case rate is higher than the rate among their white counterparts. Figure 11. Adult HIV Infection Case Rates* by Sex and Race/Ethnicity, Diagnosed in 2014, Florida White Black Hispanic Rate Ratios: MALES Black:White, 5.5:1 Hispanic:White, 2.8:1 FEMALES Black:White, 13.8:1 Hispanic:White, 2.0: Male Female *Source: Population estimates are provided by Florida CHARTS as of 7/9/ Adult Male HIV Infection and AIDS Cases by Mode of Exposure Among the male HIV infection and AIDS cases diagnosed for 2014, male-to-male sexual contact (MSM) was the most common risk factor (77% and 65% respectively) followed by cases with a heterosexual risk (18% for HIV and 25% for AIDS) (Figure 12). HIV cases tend to represent a more recent picture of the epidemic. DRAFT Integrated HIV Prevention and Patient Care Plan 13

14 Figure 12. Adult Male HIV Infection and AIDS Cases by Mode of Exposure, Diagnosed in 2014, Florida HIV Infection N=3,602 AIDS N=1,694 3% 2% 18% <1% MSM IDU MSM/IDU Heterosexual Other 7% 3% 25% <1% 77% 65% *Other includes hemophilia, transfusion, perinatal, other pediatric risks and other confirmed risks 17. Adult Female HIV Infection and AIDS Cases by Mode of Exposure Among the female HIV infection and AIDS cases diagnosed for 2014, heterosexual contact was the highest risk (90% and 86% respectively) (Figure 13). Figure 13. Adult Female HIV Infection and AIDS Cases by Mode of Exposure, Diagnosed in 2014, Florida HIV Infection N=997 <1% 10% AIDS N=668 2% 12% IDU Heterosexual Other* 90% 86% *Other includes hemophilia, transfusion, perinatal, other pediatric risks and other confirmed risks DRAFT Integrated HIV Prevention and Patient Care Plan 14

15 Number of Cases 18. Ten Year Trend of Adult Male HIV Infection Cases by Mode of Exposure Over the past ten years, male to male sexual contact (MSM) remains as the primary mode of exposure among adult male HIV infection cases in Florida; this trend is followed by heterosexual contact (Figure 14). The number of adult males infected with HIV by way of male to male sexual contact remained fairly level from 2005 to Whereas the number of adult male infected with HIV by way of heterosexual contact decreased by 28% over the same time period. Figure 14. Adult Male HIV Infection Cases by Mode of Exposure and Year of Diagnosis, , Florida MSM IDU MSM/IDU Heterosexual 3,500 3,000 2,500 2,000 1,500 1, Year of Diagnosis 19. Ten Year Trend of Adult Female HIV Infection Cases by Mode of Exposure Over the past ten years, heterosexual contact continues to be the primary mode of exposure among adult female HIV infection cases in Florida; this trend is followed by injection drug use. The number of adult females infected with HIV by way of heterosexual contact decreased by 57% from 2005 to Similarly, the number of adult female infected with HIV by way of injection drug use decreased by 54% over the same time period (Figure 15). DRAFT Integrated HIV Prevention and Patient Care Plan 15

16 Number of Cases Figure 15. Adult Female HIV Infection Cases by Mode of Exposure and Year of Diagnosis, , Florida 2,500 IDU Heterosexual 2,000 1,500 1, Year of Diagnosis 20. Ten Year Trend of Adult Male AIDS Cases by Mode of Exposure Over the past ten years, male to male sexual contact (MSM) remains as the primary mode of exposure among adult male AIDS cases in Florida; this trend is followed by heterosexual contact. The number of adult males who developed AIDS diagnosed exposure by way of male to male sexual contact decreased by 38% from 2005 to Similarly, the number of adult males who developed AIDS diagnosed exposure by way of heterosexual contact decreased by 39% over the same time period. 21. Ten Year Trend of Adult Female AIDS Cases by Mode of Exposure Over the past ten years, heterosexual contact continues to be the primary mode of exposure among adult female HIV infection cases in Florida; this trend is followed by injection drug use. The number of adult females who developed AIDS diagnosed exposure by way of heterosexual contact decreased by 50% from 2005 to Similarly, the number of adult females who developed AIDS diagnosed exposure by way of injection drug use decreased by 61% over the same time period. 22. Perinatal HIV/AIDS Cases Of the 1,220 perinatally infected babies born in Florida from 1979 through 2014, two were born as early as 1979 (Figure 16). The birth of HIV-infected babies continued to rise through In April 1994, the U.S. Public Health Service released guidelines for zidovudine (ZDV) also known as azidothymidine (AZT), used to reduce perinatal HIV transmission, and in 1995 recommendations for HIV counseling and voluntary testing for pregnant women were published. Florida law, beginning in October 1996 required the offering of HIV testing to pregnant women. As a result of this increase in testing for HIV infection, more HIV positive women could be offered ZDV during their pregnancy. Enhanced perinatal surveillance systems have documented increased use of ZDV among exposed infants and HIV-infected mothers at the prenatal, intrapartum, delivery and neonatal stages. DRAFT Integrated HIV Prevention and Patient Care Plan 16

17 Number of Cases Prevention of perinatal HIV remains a very high priority in Florida. In the past few years, the use of other medical therapies, including protease inhibitors, has supplemented the use of ZDV for both infected mothers and their babies. The use of these medical therapies has been accompanied by a decrease in the number of perinatally HIVinfected infants and is responsible for the dramatic decline in perinatally acquired HIV/AIDS since Furthermore, numerous initiatives have contributed to the reduction in these cases. Major initiatives include: seven Targeted Outreach to Pregnant Women Act (TOPWA) programs, three perinatal nurses located in the most heavily impacted counties, social marketing, and provider education. These initiatives have helped to further educate local providers in the importance of testing pregnant women for HIV and then offering effective treatment during the pregnancy and at delivery to further decrease the chances of vertical transmission. The use of these medical therapies has been followed by a decrease in the number of perinatally HIVinfected children and a dramatic decline in perinatally-acquired HIV/AIDS cases since There was a sharp decrease in 1994 with a leveling trend from 2002 to 2007, followed by another sharp decrease through In summary, these successful initiatives have resulted in a 95% decline in HIV-perinatally infected births in Florida from 1993 (N=109) to 2014 (N=6). Figure 16. Perinatally Acquired HIV Infected Cases, Born in Florida, by Year of Birth, (N=1,220) Birth # % change % % % % % % % % % % % % Year of Birth 23. Prevalence Estimate of HIV Disease in the U.S. and Florida Assessment of the extent of the HIV epidemic is an important step in community planning for HIV prevention and HIV/AIDS patient care. The HIV prevalence estimate is the estimated number of persons living with HIV infection, this includes those living with a diagnosis of HIV or AIDS and those who may be infected but are unaware of their serostatus. According to recent estimates published by CDC, more than 1.2 DRAFT Integrated HIV Prevention and Patient Care Plan 17

18 million people are currently living with HIV infection in the U.S. (CDC, 2015c) Florida has consistently diagnosed 10% to 12% of the national AIDS morbidity and currently accounts for 11% of all persons living with AIDS in the U.S. The Florida Department of Health now estimates that at least 126,100 persons, or roughly 11% of the national total, are currently living with HIV infection in Florida as of the end of There are some small differences and a few substantive differences between the proportional distributions of populations living with HIV infection in Florida as compared to the U.S. as a whole as noted in the table below (Table 3). Florida has a larger proportion of women (28%) compared to the U.S. (24%). By race/ethnicity, Florida has a larger proportion of blacks (47%) compared to the U.S. (43%). By mode of exposure, Florida has a smaller proportion of MSM (48% vs. 53%) and IDU (9% vs. 14%). However, Florida has a larger proportion of cases with heterosexual contact (37% vs. 26%). By age group, Florida has a larger proportion of persons living with HIV infection older than the age of 50 (47% vs. 42%). Table 3. Persons Living with HIV Disease by Selected Demographics and Risk Factors in the U.S. (2013)* and Florida (2014)** Subgroup U.S. (N=933,941) Florida (N=109,969) Male 76% 72% Female 24% 28% White 32% 30% Black 43% 47% Hispanic 20% 21% Other 5% 2% MSM 53% 48% IDU 14% 9% MSM/IDU 5% 4% Heterosexual 26% 37% Other 2% 2% Age % 4% Age % 49% Age % 47% * Source: U.S. Data: CDC, HIV Surveillance Report, 2014, Vol. 26, Table 18a, estimated for 50 states with confidential name-based HIV infection reporting. Living data through 2013 is most recent available. **Florida Data: FL Department of Health, HIV/AIDS Section, ehars, alive and diagnosed through 2014, as of 06/30/2015. DRAFT Integrated HIV Prevention and Patient Care Plan 18

19 24. Persons Living with HIV Disease by County of Residence Through 2014, there were approximately 110,000 persons living with HIV disease in Florida. Virtually every county in Florida had at least six people living with HIV. Seven counties (Broward, Duval, Hillsborough, Miami-Dade, Orange, Palm Beach, and Pinellas) had more than 4,000 individuals living with HIV (Figure 17). These seven counties are lead counties which are incorporated in the six EMAs (Part A areas) in Florida. Combined, these seven counties represent 71% of the state s total HIV population. Figure 17. Persons Living with HIV Disease by County of Residence,* through 2014, Florida Living Case Counts N=109,969 1 to to 1,000 1,001 to 1,500 > 1, *County totals exclude Department of Corrections cases (N=4,085). Numbers on counties are cases reported. DRAFT Integrated HIV Prevention and Patient Care Plan 19

20 Number of Deaths 25. Impact of HIV-Related Deaths HIV/AIDS deaths decreased markedly from after the advent of highly active anti-retroviral therapy (HAART) in A leveling of the trend since 1998 may reflect factors such as viral resistance, late diagnosis of HIV, adherence problems, and lack of access to or acceptance of care (Figure 18). Overall, there has been a 79% decline in the number of Florida resident deaths due to HIV disease from 1995 (the peak of resident HIV-related deaths) to Since 2007, deaths have maintained a downward trend. According to the Florida Bureau of Vital Statistics, for persons years of age, in 2014 HIV was the: 6 th leading cause of death. 5 th leading cause of death among blacks. 9 th leading cause of death among whites (down from 8 th in 2013). 7 th leading cause of death among Hispanics (up from 8 th in 2013). 6 th leading cause of death among men and the 5 th leading cause of death among women. Figure 18. Resident Deaths due to HIV Disease, by Year of Death, , Florida 5,000 4,500 4,000 3,500 3,000 2,500 2, Race/Ethnicity 2014 No. rate* White Male White Female Black Male Black Female Hispanic Male Hispanic Female Other** TOTAL ,500 1, Year of Death *Source: Florida Department of Health, Office of Vital Statistics, Death Certificates (as of 05/31/2015). Population data are provided by Florida CHARTS 07/09/2015. **Other includes American Indian/Alaska Native, Asian/Pacific Islander, and multi-racial individuals. DRAFT Integrated HIV Prevention and Patient Care Plan 20

21 26. Prevention of HIV Disease in Florida The most common ways HIV is transmitted are through anal or vaginal sex or sharing drug injection equipment with a person infected with HIV (CDC, 2015a)., therefore it is important to take steps to reduce the risks associated with these. They include: Know your HIV status. Everyone between the ages of 13 and 64 should be tested for HIV at least once. If you are at increased risk for HIV, you should be tested for HIV at least once a year. If you have HIV, you can get medical care, treatment, and supportive services to help you stay healthy and reduce your ability to transmit the virus to others. If you are pregnant and find that you have HIV, treatments are available to reduce the chance that your baby will have HIV. Abstain from sexual activity or be in a long-term mutually monogamous relationship with an uninfected partner. Limit your number of sex partners. The fewer partners you have, the less likely you are to encounter someone who is infected with HIV or another sexually transmitted disease (STD). Correct and consistent condom use. Latex condoms are highly effective at preventing transmission of HIV and some other sexually transmitted diseases. Natural or lambskin condoms do not provide sufficient protection against HIV infection. Get tested and treated for STDs and insist that your partners do too. Male circumcision has also been shown to reduce the risk of HIV transmission from women to men during vaginal sex. Do not inject drugs. If you inject drugs, you should get counseling and treatment to stop or reduce your drug use. If you cannot stop injecting drugs, use clean needles and works when injecting. Obtain medical treatment immediately if you think you were exposed to HIV. Sometimes, HIV medications can prevent infection if they are started quickly. This is called post-exposure prophylaxis. Participate in risk reduction programs. Programs exist to help people make healthy decisions, such as negotiating condom use or discussing HIV status. Florida s comprehensive HIV prevention program provides high-quality culturally appropriate prevention and education services to Florida s at-risk and HIV-infected populations. The program s overarching goals include reducing the number of new HIV infections, increasing the proportion of HIV-infected persons who know their status, linking HIV-infected persons to care and support services, and reducing risky behaviors that might lead to HIV/STD infection. Our comprehensive program has multiple components, each designed around evidence-based models that are targeted, monitored, and evaluated to ensure maximum effectiveness. The HIV prevention community planning process provides a voice for persons affected by and infected with HIV. The process is designed to allow information to flow from the top down and from the bottom up and to ensure that all of our prevention activities are aligned with our comprehensive prevention plan. DRAFT Integrated HIV Prevention and Patient Care Plan 21

22 27. Co-morbidity data This subsection of the epidemiologic overview reflect documented co-morbidity data captured in enhanced HIV/IDS Reporting System (ehars) in Florida. In 2014, of the 105,884 people living with HIV/AIDS in Florida eight (less than 1%) were diagnosed with Tuberculosis, 769 (less than 1%) were diagnosed with Syphilis, 1,270 (approximately 1.2%) were diagnosed with Gonorrhea, and 1,354 (approximately 1.3%) were diagnosed with Chlamydia. Furthermore, data through 2014 show that 10,107 (10%) of people living with HIV/AIDS were also living with Hepatitis C (which includes history of acute and/or chronic viral Hepatitis C). In terms of other factors/surrogate markers documented during 2014, of the 105,884 people living with HIV/AIDS in Florida, 666 (less than 1%) were homeless, 15,169 (14%) have a history of substance abuse, and 4,124 (4%) have a history of chronic mental illness. DRAFT Integrated HIV Prevention and Patient Care Plan 22

23 References HIV Basics. (2015). Retrieved April 13, 2015, from HIV in the United States: At A Glance. (n.d.). Retrieved April 13, 2015, from (2015, November). Retrieved December 15, 2015, from Additional Resources Additional information about HIV and AIDS can be found on the CDC s website in English and Spanish at Please visit the HIV/AIDS surveillance webpage to access additional reports including fact sheets, epidemiologic profiles, monthly surveillance report, slide shows and much more at To locate services across the state please visit DRAFT Integrated HIV Prevention and Patient Care Plan 23

24 Summary of Behavioral Studies This section of the Statewide Coordinated State of Need summarizes the various behavioral studies conducted in Florida within the past several years. The information derived from behavioral studies outlined in this section were taken from National HIV Behavioral Surveillance (NHBS), Youth Risk Behavioral Surveillance System (YRBSS), and Behavioral Risk Factor Surveillance System (BRFSS). The final portion of this section conclude with qualitative information from a focus group of transgender women of color. National HIV Behavioral Surveillance (NHBS) was created by Centers for Disease Control and Prevention (CDC) in 2003 for the purpose of conducting behavioral surveillance among persons at high risk for HIV infection (CDC, 2015). The Florida Department of Health (DOH), HIV/AIDS Section is funded by CDC to implement the NHBS system to monitor behaviors that place people at risk for HIV infection (DOH Behavioral Surveillance, n.d.). NHBS involves a repeated, cross-sectional survey and voluntary HIV testing of populations at high risk for HIV infection: men who have sex with men (MSM), injection drug users (IDU), and heterosexuals at risk for HIV infection (HET) (DOH Behavioral Surveillance, n.d.). NHBS activities are implemented in rotating cycles so that data are collected from each risk group approximately once every three years; these study cycles are referred to as NHBS-MSM, NHBS-IDU, and NHBS- HET (DOH Behavioral Surveillance, n.d.). Individuals who consent to participate undergo an anonymous interview and are paid for their time. The study provides data on 1) trends in sexual and drug-use risk behaviors, 2) HIV prevalence and incidence, 3) HIV testing patterns, and 4) the use and impact of prevention services (DOH Behavioral Surveillance, n.d.). The overarching goal of NHBS is to help evaluate and direct local and national prevention efforts. The third round of data collection with IDUs occurred August 2012 December Respondent-driven sampling (respondents refer their IDU associates, friends, etc.) was used to recruit 713 IDUs in Miami-Dade County, of whom 524 were eligible for participation. Consenting participants completed an anonymous interview consisting of the core NHBS questionnaire and a local questionnaire tailored to Miami-Dade County, Florida. NHBS-IDU2 participants were offered anonymous HIV counseling and testing, as well as referrals to psychosocial and healthcare services. NHBS-IDU3 Sample 524 completed the questionnaire and were tested for HIV infection Eligibility was limited to persons who reported injecting non-prescription drugs in the past 12 months; had physical evidence of recent injection (e.g., fresh track marks, abscesses) or evidenced knowledge of common injection practices; reported residence in Miami-Dade county; reported being 18 years of age or older; were male or female (not transgender); did not report previous participation in the NHBS-IDU1 or NHBS-IDU2 study cycle; and were alert and able to complete the questionnaire in English or Spanish language. Demographic Characteristics of the Sample (excludes self-reported HIV positives, N=473) DRAFT Integrated HIV Prevention and Patient Care Plan 24

25 The average age was 46 years; 54% of the sample was between years of age 29% were white, 23% black, 47% Hispanic, and 1% other/mixed race/ethnicity 74% male and 26% female 44% self-reported hepatitis C (HCV) infection 86% identified as heterosexual, 11% identified as bisexual and 3% as gay 79% met depression criteria (according to CES-D 10) 74% were without health insurance 68% reported homelessness during the past 12 months 54% were incarcerated during the past 12 months 65% have at least a high school education 44% had an annual income under $5,000 Characteristics of Injection Drug Use 81% reported injecting for over 5 years; with an average of 17 years of injection Over half (55%) of cocaine injectors reported injecting cocaine more than once a week 62% of crack injectors reported injecting crack more than once a week Types of Drugs Injected in Past 12 Months 1 The majority (95%) reported heroin injection Over 2/3 (68%) reported speedball (heroin and cocaine combined) injection Nearly 1/2 (47%) reported cocaine injection; over 1/3 (37%) reported crack injection 1/6 (17%) reported Oxycontin (oxycodone) injection 7% reported amphetamine (Crystal, Speed, Crank, etc.) injection Injection Risk Behaviors in Past 12 Months 1 73% reported sharing injection equipment after someone used them o Higher among younger IDUs (ages 18-29) 81% 58% reported sharing syringes Percent reported sharing other injection equipment in the past 12 months Sexual Risk Behaviors-Men 1, 2 86% reported unprotected vaginal sex with a female partner 41% reported unprotected anal sex with a female partner 11% reported unprotected anal sex with a male partner 11% reported unprotected vaginal or anal sex with both a male and female partner Sexual Risk Behaviors-Women 1, 2 78% reported unprotected vaginal sex with a male partner DRAFT Integrated HIV Prevention and Patient Care Plan 25

26 26% reported unprotected anal sex with a male partner HIV Seroprevalence 14% tested HIV positive of those positive 68% male;32% female Of the individuals who tested positive and were unaware of their HIV status 58.8% were male, and 40% were female 9% self-reported as HIV positive (n=524) HIV Testing The majority 90% have tested for HIV in their lifetimes More than half (59%) have tested for HIV in the past 12 months 1 The most frequently reported facilities administering participants most recent HIV test include correctional facilities (25%), street outreach programs 18%, and community health center/public health clinic (11%) 1 HCV Testing 76% reported testing for HCV in their lifetime Among all participants 18% reported testing for HCV in the past 12 months Receipt of Prevention Services in Past 12 Months & Healthcare Experiences 37% reported receiving free condoms 9% reported receiving an individual-level intervention 3% reported in a group-level intervention The majority 63% reported visiting a healthcare provider in the past 12 months; of these, 28% were offered an HIV test 1 Of the participants who self-reported being HIV positive, (56.5%) reported currently taking HIV medication History of Substance Abuse Treatment 20% reported never participating in substance abuse treatment in lifetime 77% reported participating in substance abuse treatment in lifetime 23% reported participating in substance abuse treatment in past 12 months Beliefs on How HIV Can Be Transmitted Participants received the following list and stated whether or not they believed that each item represents a means by which HIV can be spread. The percentages represent yes responses. Sharing needles/syringes to inject drugs (99%) Vaginal sex (97%) Anal sex (96%) Oral sex (77%) DRAFT Integrated HIV Prevention and Patient Care Plan 26

27 Receiving a blood transfusion (80%) Donating blood (66%) Mosquitoes (39%) Using public toilets (8%) Food (6%) Drinking fountains (1%) 1 Excludes persons diagnosed with HIV infection over 12 months ago 2 Includes main, casual and exchange (money, drugs, etc.) partners The third cycle of data collection (September December 2013) focused on heterosexuals at risk for HIV infection. For this cycle, CDC defined a heterosexual at risk for HIV infection as an adult with (1) a physical or social connection to a high-risk area and (2) at least one opposite sex partner in the past year. The sampling methodology of HET3 is similar to the sampling methodology of HET2. Staff performed formative research, and sampling was concentrated in the identified high-risk areas (HRAs). High-risk areas were defined as geographic areas with high rates of heterosexually-acquired HIV and poverty. To identify these areas, staff used U.S. Census Bureau poverty data and Florida DOH HIV/AIDS case data. Within the HRAs staff obtained 595 eligible participants. Consenting participants completed an anonymous interview consisting of the core NHBS questionnaire and a local questionnaire tailored to Miami-Dade County, Florida. NHBS-HET3 participants were offered anonymous HIV counseling and testing, as well as referrals to psychosocial and healthcare services. NHBS-HET3 Sample 595 interviews were performed, and 591 individuals were tested for HIV between September 2013 and December Eligibility was limited to individuals who: reported residence in Miami-Dade County; years of age; having at least one opposite-sex partner in the previous 12 months; male or female (not transgender); not previously participating in the NHBS-HET1 or NHBS-HET2 cycle; and ability to complete the interview in English or Spanish. Demographic Characteristics of the Sample (excludes self-reported HIV positives, N=548) A majority (76%) were black; 20% were Hispanic,2% white, and 2% other 51% were male and 49% were female A majority (32%) were 50+ years of age; 9% 18-22, 17% 23-29, 17% 30-39, 25% A majority (88%) self-identified as heterosexual; 11% as bisexual A majority (85%) were born in the United States DRAFT Integrated HIV Prevention and Patient Care Plan 27

28 More than half (56.5%) were without health insurance at the time of their interview 53% reported annual income of less than $10,000 A majority (45%) were unemployed at the time of their interview 44% were depressed (according to the CES-D 10) 29% have less than a high school education 15% were incarcerated in the past 12 months 5.5% self-reported as being diagnosed with hepatitis C (HCV) 10% were homeless at the time of their interview HIV Prevalence 11.7% tested positive for HIV: 12% of males; 11% of females o Of participants reporting only heterosexual risk in their lifetime (n=547) 1, 9.5% tested HIV positive: 9.20% male; 9.79% female Of the individuals that tested positive for HIV 22% had been homeless within the past 12 months, 20% self-reported HCV diagnosis, and 32% reported crack cocaine use in the past 12 months. 38% participants testing positive were unaware of their HIV status: 52.8% male; 21% female HIV Testing 85% tested for HIV in their lifetime 44% tested for HIV in the past 12 months 2 Of the individuals that were previously tested for HIV, Hispanics tested the least (75%) Individuals that received the most HIV testing within the past 12 months had the following characteristics: years of age (48%), female (44%) White non- Hispanic, and Other (73%) having health insurance (49%), income over $40,000 (63%) The most frequently reported facilities administering participants most recent HIV tests include: HIV street outreach program (28%), doctors office (private)/public health clinic (17%) HIV counseling and testing site (13.5%), and correctional facility (4%) Sexual Risk Behaviors among Males that Reported Sex with Males or Females in the Past 12 Months 61% reported unprotected vaginal or anal sex with a main partner 62% reported unprotected vaginal or anal sex with a casual or exchange (exchanging sex for money, drugs etc.) partner 79% reported more than one sex partner DRAFT Integrated HIV Prevention and Patient Care Plan 28

29 3% reported unprotected vaginal or anal sex with male and female partners: 5% among black men, 3% among white men Sexual Risk Behaviors among Females in the Past 12 Months 67% reported unprotected vaginal or anal sex with a main partner 48% reported unprotected vaginal or anal sex with a casual or exchange partner 62% reported more than one sex partner Receipt of Prevention Services in the Past 12 Months and Healthcare Experiences 42% received condoms, 70% stated use of the free condoms 9.4% participated in an individual-level 3 intervention, 7% participated in a grouplevel intervention 4 Over half (72%) visited a healthcare provider in the past 12 months; of these 2, 45% were offered an HIV test Of participants who self-reported being HIV positive 88% reported currently taking HIV medication Drug Use in the Past 12 Months 43% reported marijuana use 22% reported cocaine use, 13% reported crack cocaine use 1% reported injection of illicit drugs; 1.6% reported ever injecting drugs 40% reported heavy alcohol use 5 in the past 30 days: 39% males, and 40% females Of cocaine users 67% reported use at least once a week; of crack cocaine users 63% reported use at least once a week and 22% reported use more than once a day Beliefs on How HIV Can Be Transmitted Participants received the following list and stated whether or not they believed that each item represents a means by which HIV can be spread. The percentages represent yes responses. Sharing needles/syringes to inject drugs (99%) Vaginal sex (98%) Anal sex (96%) Oral sex (84%) Receiving a blood transfusion (87%) Donating blood (68%) Mosquitoes (48%) Using public toilets (16%) Food (12%) Drinking fountains (11%) DRAFT Integrated HIV Prevention and Patient Care Plan 29

30 1 Analysis excludes persons reporting IDU or MSM risk behavior (ever) 2 Analysis excludes persons diagnosed with HIV over 12 months ago 3 A one-on-one conversation with an outreach worker, counselor, etc. about HIV prevention 4 A structured session involving group participation about HIV prevention 5 5 or more drinks in one sitting for males; 4 or more drinks in one sitting for females The following summary contains findings from the fourth MSM cycle of NHBS data collection, which was conducted in Please note that the following information is preliminary as of March NHBS-MSM4 Sample 580 participants were screened, 549 eligible participants were interviewed, and 540 eligible participants were tested for HIV between July 2014 and December Eligibility was limited to persons who: reported residence in Miami-Dade County; reported being 18 years of age or older, reported no previous participation in NHBS during the current survey cycle, and were alert and able to complete the questionnaire in English or Spanish language. In addition to these basic eligibility criteria, participation in the 2014 NHBS cycle was limited to persons who (1) were male at birth, (2) reported their gender as male, and (3) reported oral or anal sex with a male partner during their lifetime. Demographic Characteristics of the Sample (N=540) A majority (31%) were years of age; 11% 18-22, 27% 30-39, 20% 40-49, and 11% 50 or older 8% were white, 30% black, 61% Hispanic, and 1% other/mixed race/ethnicity 44% were born outside of the U.S. (17% born in Cuba) 78% identified as gay/homosexual, 21% identified as bisexual and 1% as straight/heterosexual 31% met depression criteria (according to CES-D 10) 41% were without health insurance 54% were employed full-time, 19% employed part-time and 18% unemployed 42% reported annual income of less than $20,000, 28% reported annual income between $20,000 and $39,000, 18% reported annual income between $40,000 and $74,000, and 13% reported annual income $75,000 or more 89% had never been homeless 9% were incarcerated during the past 12 months 8% reported with less than high school education, 30% reported with high school education/ged, 37% reported with some college or associates/technical degree, and 25% reported with college degree or higher HIV Seroprevalence (N=540) DRAFT Integrated HIV Prevention and Patient Care Plan 30

31 29% of participants tested HIV positive 31% of participants who tested positive were unaware they were HIV positive HIV Seroprevalence and Awareness by Race/Ethnicity (N=540) 31.3% of black MSM tested HIV positive o 36% unaware of their infection 24.3% of Hispanic MSM tested HIV positive o 27.8% unaware of their infection 15.6% of white MSM tested HIV positive o 14.3% unaware of their infection HIV Testing (N=548) 95.9% tested for HIV in their lifetime 70.9% tested for HIV in the past 12 months 1 o 70.3 among black MSM o 70.3% among Hispanic MSM o 76.2% among white MSM Facility Administering HIV Test in past 12 months (N=477) HIV counseling and testing site (37%) Public health clinic (17%) Private doctor s office (13%) HIV street outreach/mobile unit (20%) Hospital (inpatient) (3%) Correctional facility (2%) Healthcare Experiences (N=549) 70% of the sample visited a healthcare provider in the past 12 months o Of those who saw a healthcare provider in the past 12 months 1, 32.4% were offered an HIV test STI Testing in past 12 months 2 (N=546) Syphilis: o Tested in past 12 months: 45.2% o Tested positive in past 12 months: 7.3% Gonorrhea: o Tested in past 12 months: 44.3% o Tested positive in past 12 months: 4.9% Chlamydia: o Tested in past 12 months: 43.2% o Tested positive in past 12 months: 4.4% DRAFT Integrated HIV Prevention and Patient Care Plan 31

32 Syphilis Testing and Infection in past 12 months among HIV negative and HIV positive MSM 3 (N=536) Tested for syphilis in past 12 months: o 37.4% of HIV negative serostatus MSM o 67.1% of HIV positive serostatus MSM Tested positive for syphilis in past 12 months: o 5.1% of HIV negative serostatus MSM o 13.6% of HIV positive serostatus MSM Sexual Risk Behaviors in past 12 months (N=451) 4 84% reported sex with males only in the past 12 months 16% reported sex with males and females in the past 12 months 40% had more than 5 male sex partners 22% had more than 10 male sex partners Sexual Risk Behaviors: Most Recent Main Male Partner (N=451) 4 57% of the sample had a main 5 male partner in the past 12 months Of the MSM with a main male partner, 64% had unprotected anal sex with a main partner in the past 12 months Of those reporting sex with a main male partner at last sex act (n=112), 18% reported not knowing the partner s HIV status Sexual Risk Behaviors: Most Recent Non-Main Male Partner (N=451) 4 83% had a non-main 6 male partner in the past 12 months Of the MSM with a non-main male partner, 35% had unprotected anal sex with a non-main partner in the past 12 months Of those reporting sex with a non-main male partner at last sex act (n=274), 70% reported not knowing the partner s HIV status Alcohol and Drug Use in past 12 months (N=548) 41% reported marijuana use 24% used cocaine, 13% used Ecstasy, 9% used amphetamines, 5% used downers 3% reported ever injecting drugs 56% reported heavy alcohol use 7 in the past 12 months 34% reported bring drinking 8 in the past 12 months Receipt of Prevention Services in past 12 months (N=548) 78.8% received free condoms DRAFT Integrated HIV Prevention and Patient Care Plan 32

33 o 80.5% of those who received free condoms say they used the free condoms 18.6% report participating in an individual-level intervention 9 8% report participating in a group-level intervention 10 1 Analysis excludes persons diagnosed with HIV over 12 months ago 2 STI testing and infection based on self-report 3 Syphilis testing and infection based on self-report, HIV serostatus based on HIV test result 4 Excludes self-reported HIV positive 5 Someone you have sex with and who you feel committed to above anyone else (e.g., girlfriend/boyfriend. wife/husband, significant other, life partner) 6 Someone you have sex with but do not feel committed to or don t know very well 7 5 or more drinks in one sitting in the past 12 months 8 5 or more drinks in one sitting at least once a month in the past 12 months 9 a one-on-one conversation with an outreach worker, counselor, or prevention program worker about preventing HIV (excluding HIV pre- and post-test counseling sessions) 10 an organized session involving a small group of people to discuss ways to prevent HIV [Source: Research and Policy Coordinator, Mr. John-Mark Schacht, John- Mark.Schacht@flhealth.gov ] Youth Risk Behavioral Surveillance System (YRBSS) is a statewide, schoolbased confidential survey of Florida s public high school students (9 12 grade levels). The purpose of the Youth Risk Behavior Survey (YRBS) is to monitor priority health-risk behaviors that contribute substantially to the leading causes of death, disability, and social problems among youth. The YRBS is based on a two-stage cluster probability sample design. First, a random sample of public high schools is selected for participation in the survey. Second, within each selected school, a random sample of classrooms is selected, and all students in those classes are invited to participate in the survey. The responses of the survey participants are weighted to be representative of all Florida public high school students (as cited in DOH, YRBS, n.d.). Over a 10 year trend analysis according to 2015 Youth Risk Behavior Survey results, there has been a decrease (from 34.5% in 2013 to 33.8% in 2015) in the percentage of students who reported their doctor or nurse discussed ways to prevent pregnancy, AIDS, or other sexually transmitted diseases (STDs) (during their last check-up, among students who have had a check-up). Likewise, there has been in a decrease (from 56.4% in 2007 to 43% in 2015) in the percentage of students who have talked about AIDS or HIV infection with their parents or other adults in their family. In 2015, 12.6% of high school students reported being tested for HIV (not including tests done when donating blood). Meanwhile, 73.4% of high school students report receiving AIDS or HIV infection education (as cited in DOH, YRBS, n.d.). [Source: Florida Youth Survey Coordinator, Mr. Thomas Troelstrup, Thomas.Troelstrup@flhealth.gov ] DRAFT Integrated HIV Prevention and Patient Care Plan 33

34 Florida is one of 50 states conducting the Behavioral Risk Factor Surveillance System (BRFSS) with financial assistance from CDC. BRFSS is a state-based telephone surveillance system designed to collect data on individual risk behaviors and preventive health practices related to the leading causes of morbidity and mortality in the United States. Information from the survey is used for health planning, program evaluation, and monitoring health objectives within the Department of Health. The target population of BRFSS are people 18 years of age or older, who reside in a Florida household. According to 2014 Florida BRFSS data, overall 43.1% of adults reported ever been tested for HIV. The following figure is a breakdown of the respondents who answered the BRFSS question pertaining to HIV/AIDS screening: Figure 1: 2014 Florida BRFSS Data, HIV/AIDS Screening [Source: Florida BRFSS Coordinator, Mr. Junwei Jiang, Junwei.Jiang@flhealth.gov ] Although, quantifiable data on the Transgender community has historically been and continues to be difficult to collect and measure, a recent analysis of Enhanced HIV/AIDS Reporting System (ehars) data shows that as of February 2016 of the DRAFT Integrated HIV Prevention and Patient Care Plan 34

35 adults living with HIV/AIDS there were 5 females who transitioned to males and 246 males who transitioned to females (this analysis was performed by comparing birth sex variable to current sex variable in ehars). Qualitative information was derived from a community-based organization known as, Empower U Federally Qualified Health Center and Florida Memorial University Healthy Lifestyle Choices Project. Transgender Women of Color Focus Group Three March 21, 2015 The following table is an excerpt from a focus group of Transgender Women of Color: Table 1: Question and Response Question 1: How do you feel the community views you as a transgender? I m not a drag queen, they don t know the difference When I go to straight clubs they treat me right, but when I go to gay clubs they see the old version of me At first they see me as a lady, but then they get confused, How did you get to look like that? They don t understand my transition They look at us as if we are only as sex objects, we re all just prostitutes Most of the girls expressed acceptance in a limited way. We have experienced our fair share of negative comments, especially on Facebook. Question 2: In what ways would you like support from the community? Question 3: How much of an impact do you have in the trans community Question 4: Do you feel like there is We need people to be less judgmental, just view us as people, as human beings, and give us respect Would like to see mutual respect from others in our community, such as Drag Queens, Cross Dressers etc too much in fighting or competition They try to downgrade me before I even start to reach my goals I d like to see more Doctors that know how to treat me & help my transition I want Safer Housing, Jobs & laws to protect me from harm. I don t feel comfortable seeing Doctors, they don t respect me. Several girls are professional Entertainers, therefore most believed they have major impact in their local communities. I ve made a name for myself, so I like to give back & give new girls tips & advice on how to make it New girls need to be resourceful, so they come to ask advice & how to find shortcuts Most stated they did not believe there was adequate representation of Trans Girls, not anyone out there advocating for their needs as much as they should be. Talked a bit about Yasmeen, Kimberly Starr & Felicity Lenore. Also mentioned Xavier Thomas, 1 st openly Trans black from Canada. Aisha, very popular on Instagram & Twitter, also Camille Lewis for starting Trans Illuminati. For F2M Trans guys definitely Sir DRAFT Integrated HIV Prevention and Patient Care Plan 35

36 a decent representation for the trans community? Question 5: What are some of the health concerns that transwomen have? Question 6: What factors would you say prevent you from having better health? Question 7: Do you have insurance? Question 8: If you have a doctor, what would an ideal check-up look like for you? Question 9: How do you think or how is a trip to the emergency room ( ER) for you? Question 10: What surgical procedures do you think insurance Carter from Black Trans Men of Texas, noted for their sense of empowerment & helping other Trans guys in the community get connected and secure. Some felt the role includes an obligation to make an impact on issues to advance the causes of transgender folks in general. Resounding consensus on Hormone treatment / management and how to obtain them safely. [The 3 rd group in a row that this was the overwhelming consensus item] Worried cause I take them from friends, not really knowing what s in them I need a way to get them that is safe, and no hassle to get them They say most girls have no options - the risk is there, but they have no insurance coverage, or cannot afford the normal route. We have to go underground to get medical care and the medications we need. Mentioned Liver Failure, Prostrate issues, Depression due to hormones & life in general. Everything is up to you Lack of Insurance coverage identified as biggest barrier. You have to save it up till you have enough to pay for street care Most commented about experiences they had with ER visits as the most common way to access care. Half of the group did have some kind of access, mostly Medicaid, but 3 had private insurance. Blood Tests, Sickle Cell anemia, back pains, most emphasized labs. Most want to see a doctor monthly. [This is the second group where there is no mention of STIs, HIV nor Hepatitis] One person had a very negative experience, religious person condemning her. Most were OK with existing policy of identifying you by your Driver s license during an emergency. 1 person had a very bad experience where the staff were coming in & looking at her & giggling, called her an it. Should cover most everything, half of the group said include sex reassignment surgery, especially breast implants & augmentation. However a third of the group believed only essential surgeries should be covered, and not those deemed cosmetic in nature. Unanimous for Hormone replacement DRAFT Integrated HIV Prevention and Patient Care Plan 36

37 companies should cover for trans people? Question 11: Do you feel that a person needs permission for reassignment surgery? Question 12: Do you feel safe with untraditional surgery (street surgeon)? therapy services. 30% said No, remove the requirement, however the remaining 70% percent agreed it was necessary. Many said the eligible age for this should be 13, a few said 18, One person said 8 or 10 is old enough to know. No, not safe, but sometimes the only option. There is a history of safety & examples from peers; those that have a desired appearance are an indirect stamp of approval for those performing surgeries. We prefer to see people we know, and then we can judge for ourselves, and ask questions from personal experience. Depending on the type of surgery, some were willing to take the risk, based on affordability & references. Butt & Hip implants were deemed worth the risk whereas facial procedures were not. Question 13: Do you value affordability or expertise more when it comes to any surgical procedure? Question 14: What could the health department do to stop transwomen from going to street surgeons? Question 15: What concerns do you have with body enhancements and aging? Question 16: What are some of the dangers/risks involved Expertise based on results are clearly the guiding factor; several girls talked about wanting to see testimonials from other girls that had already undergone their procedures with that particular person / Doctor. Unanimous on this issue. First, make us feel welcome and have peers to work with us; then have a clear pathway of where to go. Provide some kind of financial support or subsidy for us to access give us some guidance or rating for Doctors for these surgeries Consensus on Financial support to help make the surgeries happen. Concerned about the visual effects, such as sagging, and drooping, and not looking young anymore. All of the members expressed they have older role models to see for themselves the effects of aging. Only 2 Issues face us Death & Disease; getting violently attacked or shot, and or being purposely infected with some disease! We re Risking our lives every time we get into a car, DRAFT Integrated HIV Prevention and Patient Care Plan 37

38 in being a sex worker? Question 17 How can health care professionals make sex work safer? Question18: Are you aware of preexposure prophylaxis (PrEP)? Question 19: How often do you migrate to other communities? Question 20: Is this an effective outreach method? or let someone in our hotel rooms, it s part of the job Robbed, raped, or physical violence against us No such thing as safe sex, and no one ever addresses the bigger issue, how to make things safer and avoid violence. Heard about it only 2 people did know vaguely. Don t want to take a pill, people will think I m already positive. A few do get around, 1 travels nationwide, but for over 75% of the group, there s not much travel, some girls do for entertainment bookings, but some have no car, so not much going out of local area. Less than 15% travel beyond south Florida (Tri County area) We prefer our local circles of influence Be careful how you reach out to me; not while I working whether it s corporate or on a street corner. It s hard because we as a community do not come together like other groups. We are more solitary most of the time. [Source: Community Relation Director of Empower U, Inc. Miami, Mr. Joey Wynn, JWynn@Empower-U-Miami.org ] DRAFT Integrated HIV Prevention and Patient Care Plan 38

39 References AIDS. (n.d.). Retrieved March 11, 2016, from Behavioral Survey Data. (n.d.). Retrieved March 14, 2016, from Behavioral Survey Data. (n.d.). Retrieved March 14, 2016, from CDC HIV News: HIV Infection Risk, Prevention, and Testing... (n.d.). Retrieved March 15, 2016, from National HIV Behavioral Surveillance (NHBS). (2016). Retrieved March 11, 2016, from DRAFT Integrated HIV Prevention and Patient Care Plan 39

40 B. HIV Care Continuum The HIV Care Continuum is a model that is used by federal, state, and local agencies to identify issues and opportunities related to improving the delivery of services to people living with HIV (PLWH) across the entire HIV Continuum of Care. The HIV Care Continuum has five main steps or stages including: HIV diagnosis, linkage to care, retention in care, antiretroviral use, and viral suppression. The State of Florida has developed a diagnosis-based model to identify issues and opportunities related to improving the delivery of services to high-risk, uninfected individuals. The diagnosis-based model of the HIV Care Continuum allows Florida to display each step of the continuum as a percentage of the number of PLWH who were only diagnosed. The diagnoses-based continuum directs steps that can be taken to get individuals with HIV into care and virally suppressed (<200 copies/ml). The diagnosis-based HIV care continuum shows each step of the continuum as a percentage of the number of people living with diagnosed HIV as of the end of HIV Diagnosed: The number of persons known to be diagnosed and living in Florida with HIV disease (PLWH) through 2014, regardless of AIDS status or where diagnosed, as of 06/30/15. Ever in Care: PLWH with at least 1 documented viral load (VL) or CD4 lab, medical visit or prescription since HIV diagnosis. Numerator = Ever in Care PLWH s (99,516) Denominator = HIV Diagnosed (PLWH) through 2014 (109,969) In Care: PLWH with at least 1 documented VL or CD4 lab, medical visit or prescription in Numerator = In Care PLWH s (78,124) Denominator = HIV Diagnosed (PLWH) through 2014 (109,969) Retained in care: PLWH with 2 or more documented VL or CD4 labs, medical visits or prescriptions (at least 3 months apart) in Numerator = Retained in Care PLWH s (70,287) Denominator = HIV Diagnosed (PLWH) through 2014 (109,969) DRAFT Integrated HIV Prevention and Patient Care Plan 40

41 On ART: Estimated PLWH on antiretroviral therapy (ART) in The 2013 FL Medical Monitoring Project (MMP) data are used to estimate the number and percentage of people receiving medical care and who have a documented ART prescription in their medical records in the observed year. From the 2013 FL MMP data, 95% of those in care were on ART. Numerator = PLWH on ART (74,218) Denominator = HIV Diagnosed (PLWH) through 2014 (109,969) Suppressed Viral Load: PLWH with a suppressed viral load (<200 copies/ml) on last viral load in Numerator = PLWH s with Suppressed Viral Load (64,230) Denominator = HIV Diagnosed (PLWH) through 2014 (109,969) The following table demonstrates the numerator and denominator values for the State: Percent Linded to Care in 3 months 2014 only Number and Percentage of Persons Living with HIV (PLWH) Disease Engaged in Selected Stages of The Continuum of HIV Care Florida (excl. DOC), 2014 HIV Diagnosed Ever in Care In Care Retained in Care at least once in 2014 (<200 copies/ml) # of diagnosed # of diagnosed # of diagnosed # of diagnosed # of diagnosed % at least 1 care State 83% 105, % 95,724 90% 75,240 71% 67,619 64% 71,478 68% 61,988 59% 82% On ART Viral Load Suppression The number/percent of persons whose most recent HIV VL was (1) HIV Diagnosed: Persons diagnosed and living with HIV (PLWH) in Florida through the end of (2)Ever in Care: PLWH with at least 1 documented viral load (VL) or CD4 lab, medical visit or prescription since HIV diagnosis. (3)In Care: PLWH with at least 1 documented VL or CD4 lab, medical visit or prescription in Retained in Care: PLWH with 2 or more documented VL or CD4 labs, medical visits or prescriptions (at least 3 months apart) in (4)On ART: Estimated PLWH on antiretroviral therapy (ART) in 2014 (estimated from 2013 FL MMP data). (5)Suppressed Viral Load: PLWH with a suppressed VL (<200 copies/ml) on last VL in The data used to develop the diagnosis-based Florida HIV Care Continuum stems from the merging of the following databases: Enhanced HIV/AIDS Reporting System (ehars) Florida s CAREWare Miami s Service Delivery Information System (SDIS) AIDS Drug Assistance Program (ADAP) database The analysis of data from the latter databases depends on: the completeness of laboratory reporting in ehars, the maintenance of timely death reporting, and the accurate maintenance of current PLWH addresses, accommodating for in and out migration. All of the bars in the HIV Care Continuum reflect actual data, analyzed from the matched databases with the exception of the antiretroviral therapy (ART) bar. The data for ART was estimated based on Medical Monitoring Project (MMP) data. As previously mentioned, the merging of the latter databases facilitated the data necessary to develop Florida s diagnosis-based HIV Care Continuum in alignment with any data policies protecting the identity of PLWH living in Florida. At the present time, since there are no formal policies and procedures serving as barriers for developing the HIV Continuum of Care model, the significant limitation results in assuming that persons DRAFT Integrated HIV Prevention and Patient Care Plan 41

42 not in care (based on the listed data matches above) are truly not in care. The upcoming challenges will be to develop policies and procedures, with available staff at the state health office and in the field, to evaluate those cases not in care, specify who will be responsible for trying to locate those persons not in care and ascertain how staff will carry out this process. Legal agreements may need to be drawn up if non-doh staff needs to be contracted to perform some of these duties. Additionally, continued efforts will be made to further improve the completeness of state and local data elements. Moreover, facilitating data agreements with local IT departments will allow for greater development of the HIV Care Continuum for the state, as demonstrated by the data agreement with Miami. Data sharing with the Ryan White Part A programs around the state will be assessed to coordinate programs that target the care continuum. The data for ART was an estimate based on MMP data. The estimations were applied to the State ART bars. However, the ART bar was omitted on tables with demographic and risk breakdowns because the estimated value is based on small numbers. The State anticipates obtaining more accurate data for those PLWH on ART and/or additional resources in the coming year to further include this information in future HIV Care Continuum models for the State. The State will also evaluate the use of the patient care databases along with ehars to get a more accurate estimate for the state and local areas. b. Graphic and Narrative describing disparities in engagement among five (5) key populations: DRAFT Integrated HIV Prevention and Patient Care Plan 42

43 Black MSM Black Heterosexual Males DRAFT Integrated HIV Prevention and Patient Care Plan 43

44 Male IDU DRAFT Integrated HIV Prevention and Patient Care Plan 44

45 Persons 25 to 39 years of age DRAFT Integrated HIV Prevention and Patient Care Plan 45

46 Persons 13 to 24 years of age When compared with the Continuum of HIV Care for the State of Florida, the above five (5) populations demonstrate significant disparities, particularly in the last stage, Suppressed Viral Load (<200 copies/ml). The State of Florida currently details 58% of PLWH with a suppressed viral load. The five populations of concern in this section clearly show suppressed viral load percentages below 53%. This is significant to note in observing the ultimate health outcome of treatment adherence and an individual living with HIV leading a healthier life. The HIV Care Continuum provides a framework that depicts the series of stages a person with HIV engages in, from initial diagnosis through successful treatment with HIV medication. It demonstrates the proportion of individuals living with HIV who are engaged at each stage. The state of Florida aims to measure progress among the continuum and to direct HIV resources most effectively in those services that influence each and every bar of the continuum. The development and analysis of the diagnosisbased HIV Care continuum will focus attention on those necessary collaborations amongst networks and partnerships in order to make an impact on HIV incidence throughout the state. In alignment with the National HIV/AIDS Strategy (NHAS), the HIV Care Continuum will help us achieve the goals of the NHAS: Reduce the number of people who become infected with HIV Increase access to care and improve health outcomes for people living with HIV Reduce HIV-related health disparities Though it is vital to improve engagement at every stage in the Continuum of Care, special emphasis is to be placed on viral suppression (<200 copies/ml). DRAFT Integrated HIV Prevention and Patient Care Plan 46

47 C. Financial and Human Resources Inventory To ensure that the state of Florida is meeting the goals and objectives set forth to fight the HIV/AIDS epidemic, the financial resources and capacity to provide the services outlined must be available. The following section provides a comprehensive HIV financial and human resources inventory for Florida. Components include, but aren t limited to: statewide public and private funding sources for HIV prevention, care, and treatment services; the dollar amount and the percentage of the total available funds in fiscal year (FY) 2016 for each funding source; program or service delivery; and how Florida s HIV Care Continuum is impacted. Table 1 illustrates the overall financial resources related to HIV/AIDS funding for the state of Florida. DRAFT Integrated HIV Prevention and Patient Care Plan 47

48 Funded Amount ($) Funded Amount ($) 2015 % of Total Funded Service Provider Agencies* Services HIV Care Continuum Funding Source Delivered* Steps Impacted** Ryan White Part A (6 EMA) $ 75,326, % 2, 3, 4, 5 Fort Lauderdale, FL $16,012,762 Jacksonville, FL $5,942,963 Miami, FL $26,169,425 Orlando, FL $9,625,492 Tampa, FL $9,922,280 West Palm Beach, FL $7,653,485 Ryan White Part B $ 117,881, % 2,3,4,5 Base $ 30,287,962 MAI $ 1,327,506 ADAP Earmark $ 85,677,240 ADAP Supplemental Emerging Communities $ 489,052 Ryan White Part B- Supplemental $ 4,000, % 2,3,4,5 Ryan White Part B - Shortfall Relief Funds $ 8,954, % Prevention- Part A $ 27,912, % Headquarters and Statewide $ 17,284,680 Broward $ 4,074,149 Miami-Dade $ 6,453,251 Part B - Expanded Testing Initiative $ 6,384, % 1 Headquarters and Statewide $ 3,094,126 Broward $ 2,087,748 Miami-Dade $ 1,202,578 Ryan White Part C -Early Intervention (20) $ 10,468, % 2,3,4,5 Charlotte and DeSoto County Health Department $285,000 FDOH, Bartow $526,444 NORTH BROWARD HOSPITAL DISTRICT $905,093 MCGREGOR CLINIC, INC., THE, Ft. Myers $315,875 OKALOOSA, COUNTY OF $315,875 UNIVERSITY OF FLORIDA, Gainesville $315,875 COLLIER HEALTH SERVICES,, Immokalee $507,610 DOH - Jacksonville $277,875 DOH - Key West $546,562 DOH - Labelle $341,792 UNCONDITIONAL LOVE INC, Melbourne $345,620 BORINQUEN HEALTH CARE CENTER INC, Miami $718,923 UNIVERSITY OF MIAMI $942,667 MIAMI BEACH COMMUNITY HEALTH CENTER INC. $513,098 JESSIE TRICE COMMUNITY HEALTH CENTER, INC., $737,133 Miami DOH, Orlando $1,111,183 MANATEE COUNTY RURAL HEALTH SERVICES, INC. $503,965 ST LUCIE, COUNTY OF $315,875 ST JOHNS, COUNTY OF $381,176 BOND COMMUNITY HEALTH CENTER INC, Tallahassee $560,500 State of Florida - HIV/AIDS Funding DRAFT Integrated HIV Prevention and Patient Care Plan 0

49 Part C - Capacity Building $42, % 2,3,4,5 University of Miami $42,280 Ryan White Part D $ 7,317, % 2,3,4,5 CHILDREN'S DIAGNOSTIC & TREATMENT CENTER, INC., Ft. Lauderdale, FL $1,993,705 UNIVERSITY OF FLORIDA, Gainesville $713,009 UNIVERSITY OF MIAMI $1,938,398 DOH - Orlando $868,073 BOND COMMUNITY HEALTH CENTER INC, Tallahassee $473,722 UNIVERSITY OF SOUTH FLORIDA, Tampa $1,330,301 Ryan White Part F $ 1,055, % 1,2,3,4,5 Dental Reimbursement $ 836,151 Community-Based Dental Partnership Program $ 219,230 AIDS Education and Training Center Special Projects of National Significance (SPNS) CDC Partnership for Care $ 644, % 2,3,4,5 SAMSHA $ % 1,2,3,4,5 Veteran's Administration (VA) $ % 1,2,3,4,5 Indian Health Services $ % 1,2,3,4,5 Housing Opportunities for Person with AIDS (HUD) $ 5,263, % 3 Surveillance Core $ 5,207, % 1,2,3,4,5 Medical Monitoring Project $ 874, % 4,5 Behavioral Surveillance $ 445, % General Revenue AIDS $ 47,331, % Total $ 94,209,417 $ 224,898, % * Information provided as an appendix in the local area Florida HIV Care Continuum Dashboard. ** HIV Care Continuum 1 = HIV Testing and Diagnosis: Staff, services and systems that help to identify and test HIV-positive persons who are unaware of their HIV status 2 = Linkage to Care: Staff, services and systems that help connect newly diagnosed HIV-positive persons to care 3 = Retention in Care: Staff, services and systems that help HIV-positive individuals remain engaged in care and treatment services 4 and 5 = Provision of ART: Staff, services and systems that help HIV-positive individuals access and remain adherent to antiretroviral medication DRAFT Integrated HIV Prevention and Patient Care Plan 1

50 Based on the information contained in Table 1, Ryan White funds represent the largest percentage of funding for HIV/AIDS services (XX%) followed by General Revenue dollars (XX%). The Florida HIV Continuum of Care Dashboard Tool (Appendix 1) was developed as a mechanism to gather information related to how statewide funds are distributed and HIV/AIDS program services are delivered by geographic area. The purpose and goal of the tool was to provide a statewide snapshot of HIV prevention and patient care funding and assess HIV prevention and patient care activities across the continuum of care by each of the fourteen local area consortia. Table 2 provides a snapshot of resources within health departments and local communities, as well as illustrates gaps and unmet needs by contrasting regional differences and highlighting areas of need. The information in the Florida HIV Continuum of Care Dashboard Tool was self-reported by each local area, therefore slight differences may appear in terms of funding or data reported. Additionally, specific caveats may apply since they may have alternate funding streams coming into their local areas or enhanced best practices or collaborative efforts which result in increased funding as reported by the state. DRAFT Integrated HIV Prevention and Patient Care Plan 0

51 Area Prevention Funded PTC (Y or N) Total HD Condom Sites Total Test Sites Funded HIV DIS (FTE) Funded Linkage Specialist (FTE) Funded Peer Program (FTE) Perinatal Nurse (FTE) Area Patient Care Early Intervention Services ARTAS (or ARTAS Hybrid) Peer or Near Peer Subset Outreach Funded Linkage Specialist (FTE) Funded Peer Program (FTE) Other Retention Services Area 1 $ 346,616 Area 1 $ 1,673,761 Escambia $ 319,415 Y Escambia $ 1,357, N Santa Rosa $ 10,724 N Santa Rosa $ N Okaloosa $ 16,477 N Okaloosa $ 315, N Walton $ - N Walton $ N Area 2A $ 358,200 Area 2A $ 559,071 Bay $ 242,244 Y 57 5* Bay $ 340, Y Jackson $ 84,959 N 12 1* Jackson $ 128, Y Calhoun $ 7,000 N 3 * Calhoun $ 15, Y Gulf $ 7,000 N 6 * Gulf $ 10, Y Holmes $ 7,000 N 0 * Holmes $ 20, Y Washington $ 10,000 N 8 * Washington $ 45, Y * mobile unit Area 2B $ 470,517 Area 2B $ 448,625 LEON (PRV15) $ 255,240 Y Franklin $ 24, $ 5,000 $ 19, N LEON (PRV16) $ 126,696 Y Gadsden $ 27, $ 5,000 $ 19, N GADSDEN (PRV15) $ 59,054 Y Jefferson $ 24, $ 5,000 $ 19, N GADSDEN (PRV16) $ 29,527 Y Leon $ 235, $ 5,000 $ 19, N N Liberty $ 24, $ 5,000 $ 19, N N Madison $ 24, $ 5,000 $ 19, N N Taylor $ 24, $ 5,000 $ 19, N N Wakulla $ 24, $ 5,000 $ 19, N N N N N Area 3 & 13 $ 577,466 Area 3 & 13 $ 3,383,929 Alachua $ 379,774 N Alachua $ 1,932, Y Y Marion $ 47,198 N Marion $ 342, N Bradford $ - N Columbia $ 60, N Citrus $ - N Citrus $ 152, N Columbia $ 150,494 Y Lake $ 135, N Dixie $ - N Sumter $ 39, N Gilchrist $ - N Putnam $ 166, N Area 3/13 - AIDS Hamilton $ - N Pharmaceutical Assistance $ 68, N Lafayette $ - N Area 3/13- Oral Health 0.00 Care Area 3/13 - Health Lake $ - N Insurance Premium/Cost Sharing Levy $ - N Area 3/13 - Mental Health 0.00 Services (Outpatient) Putnam $ - N Area 3/13-Medical 0.00 Transportation Area 3/13 - Referral for Sumter $ - N Health Care/Supportive Services Suwannee $ - N Union $ - N $ 80, N $ 42, N $ 13, N $ 25, N $ 325, N DRAFT Integrated HIV Prevention and Patient Care Plan 0

52 Area 4 $ 1,628,822 Area 4 $ 9,518,429 Baker $ - N 1 1 N N N N Baker $ 21,767 Y N N N N N Clay $ - N 2 2 N N N N Clay $ 155,439 Y N Y N N N Duval $ 1,628,822 Y N Duval $ 8,827, Y Nassau $ - N 2 2 N N N N Nassau $ 73,009 Y N N N St. Johns $ - N 2 2 N N N N St. Johns $ 440,611 Y N N N N N Area 5,6 & 14 $ 1,747,259 Area 5,6 & 14 $ 16,567,558 Hardee** $ - N Hardee** $ - N N Hernando $ 24,288 Y Hernando $ 659,950 N Y Highlands** $ - N Highlands** $ - N N Hillsborough $ 696,877 Y Hillsborough $ 5,984,419 N Y Manatee $ 166,253 Y Manatee $ 753,695 N Y Pasco $ 122,116 Y Pasco $ 593,628 N Y Pinellas $ 412,627 N Pinellas $ 7,194,860 N Y Polk $ 325,098 Y Polk $ 1,381,006 Y Y ** Served by Polk county providers Area 7 $ 823,082 Area 7 $ 18,741,597 Brevard $ - N N Brevard $ 1,555,987 N N Orange $ 805,082 Y Y Orange $ 13,767,200 N Y Seminole $ 4,000 N N Seminole $ 1,696,705 N N Osceola $ 14,000 N N Osceola $ 1,721,705 N N Area 8 $ 1,128,203 Area 8 $ 3,675,039 Charlotte $ 74,845 Y N N N FDOH Collier RW B $ 250,680 $ 250,680 N/A N/A N/A N/A Y Collier $ 352,182 Y N N N FDOH Collier AGR $ 140,000 $ 140,000 N/A N/A N/A N/A Y Desoto $ - N 2 9 N N N N FDOH Hendry RW C $ 341,792 $ 226,819 $ 57,017 $ 16,359 N/A $ 1 N Hendry/Glades $ 153,293 Y N N N FDOH Hendry RW B $ 122,065 $ 122,065 N/A N/A N/A N/A N Lee $ 466,562 Y N N N CollierFQHC RW C $ 507,610 $ 507,610 N/A N/A N/A $ 1 N Sarasota $ 81,321 Y N N N FDOH Desoto RW C $ 285,000 $ 285,000 N/A N/A N/A N/A N Lee McGregor RW C $ 315,875 $ 315,875 N/A N/A N/A N/A N FDOH Sarasota RW B $ 121,824 $ 121,824 N/A N/A N/A N/A N FDOH Desoto RW B $ 195,374 $ 195,374 N/A N/A N/A N/A N CAN Sarasota RW B $ 286,879 $ 286,879 N/A N/A $ 1 N/A N AHF/ICAN Lee RW B $ 170,683 $ 170,683 N/A N/A N/A N/A N McGregor Lee RW B $ 607,257 $ 607,257 N/A N/A $ 1 N/A N FDOH Lee AGR $ 230,000 $ 230,000 N/A N/A N/A N/A N FDOH Sarasota AGR $ 100,000 $ 100,000 N/A N/A N/A N/A N Area 9 $ 1,360,269 Area 9 $ 8,225,794 Health Department $ 1,360,269 Y 58 29/ Part A $ 6,576,091 $ 294,111 $ N Part B $ 635,773 $ - $ 45, N State Network $ 543,283 $ - $ N State Patient Care $ 470,647 $ - $ N Area 10 Area 10 Area 11A $ 7,061,230 Area 11A $ 27,395,678 Miami -Dade $ 7,061,230 Y Miami-Dade $ 27,395, ? N Area 11B $ 300,820 Area 11B $ 1,604,772 GR - Prev & Surv $ 73,552 Y MonroePart C $ 546,562 Y N N N N N AIDS Prev $ 127,268 Y PCN $ 259,200 N N N N N N CODHI ( AHI) $ 100,000 N GR $ 370,000 N N N N N N Monroe - Part B $ 429,010 N N N N N N Area 12 $ 162,788 Area 12 $ 2,076,760 Flagler County N Flagler County $ N Volusia County $ 162,788 Y Volusia County $ 2,076,760 N N Y N Area 15 $ 848,436 Area 15 $ 2,896,099 St. Lucie $ 754,823 N St. Lucie $ 2,500,928 $ - $ Y Indian River $ 56,405 N Indian River $ 138,240 $ - $ Y Martin $ 37,208 N Martin $ 253,309 $ - $ Y Okeechobee $ - N Okeechobee $ 3,622 $ Y Total $ 16,813,708 $ 96,767,112 *items highlighted in yellow indicate that an area is working on revised figures. Area 10 is left blank as they have not completed their submission. DRAFT Integrated HIV Prevention and Patient Care Plan 1

53 Table 2 dollar figures are those items designated as local area resources and include funding by the FDOH, direct Ryan White funding, and direct CDC dollars. Individual areas also receive funding from other sources including, but not limited to, the Veteran s Administration, Substance Abuse and Mental Health Services Administration (SAMHSA), community-based organizations (CBO), pharmaceutical grants, and private grants. Those funding amounts vary greatly by area and are excluded from the table. Those amounts can be found in Appendix 1 in the Combined Florida HIV Care Continuum Dashboard Tool for each individual area. Will include additional narrative highlighting key points or significant findings as reported by the local areas once full data is submitted. HIV Workforce Capacity Service delivery for persons at risk for and infected with HIV in Florida is provided through a network of private and public health providers. Predominant in the clinical care system are the Florida Department of Health (FDOH) outpatient clinics; Ryan White HIV/AIDS Program Part A, B, C, and D funded agencies; infectious disease and HIV specialty services at tertiary care centers; academic health centers; and the Florida Department of Corrections. Only a small percentage of the state s multi-site community health centers provide HIV services. Prevention services, case management, and other social services are mostly provided by FDOH and community-based organizations (CBOs). The Florida Medicaid Managed Care contract is administrated by Positive Healthcare for the Florida Agency for Health Care Administration. Children s Medical Services (CMS) provides care to 90% of the children with HIV in Florida. The distribution of HIV/AIDS care providers is important in assessing capacity for care and the adequacy of service delivery. The state and the federal government fund the delivery of care for the majority of people with HIV/AIDS in the region. An analysis of the distribution of Medicaid and Medipass providers in Florida shows that the counties with the highest disease prevalence also have the highest concentration of providers. The majority of providers are located within the six Eligible Metropolitan Areas (EMAs) - Ft. Lauderdale, Jacksonville, Miami, Orlando, Tampa, and West Palm Beach. Rural counties appear to have very few providers that are funded by Medicaid and Medipass. Rural providers generally see fewer HIV-infected patients and need more educational updates and expert consultation. This deficiency represents a gap in service delivery and limits access to care for underserved populations. In Florida, CMS is an integral component of the Pediatric HIV Program that provides comprehensive medical, social and related services through its network of providers. CMS pediatric clinics and referral centers are well distributed across the state and are available in the counties that have high concentrations of children with HIV/AIDS, primarily in the six EMAs. One of the tools that Florida utilizes is to link recently diagnosed person with HIV to medical care rapidly is the Anti-Retroviral Treatment and Access to Services (ARTAS). This is an individual-level, multi-session, time-limited intervention. These service DRAFT Integrated HIV Prevention and Patient Care Plan 0

54 providers are located primarily within the high incidence areas of Florida. The exception is that WellFlorida Council covers a region in north central Florida that is predominantly rural. Staffing and services are also categorized by their impact on the HIV Care Continuum. HIV Testing and Diagnosis: Staff, services and systems that help to identify and test HIV-positive persons who are unaware of their HIV status Linkage to Care: Staff, services and systems that help connect newly diagnosed HIV-positive persons to care Retention in Care: Staff, services and systems that help HIV-positive individuals remain engaged in care and treatment services Provision of ART: Staff, services and systems that help HIV-positive individuals access and remain adherent to antiretroviral medication Collaborations between funding sources Six Eligible Metropolitan Areas (EMAs) receive Part A funds to provide core medical services. These include outpatient and ambulatory health services, ADAP, AIDS pharmaceutical assistance, oral health care, early intervention services, health insurance premium and cost-sharing assistance, home health care, medical nutrition therapy, hospice care, home and community-based health services, mental health, outpatient substance abuse care, medical case management, and treatment adherence services. Support services must be linked to medical outcomes and may include outreach, medical transportation, linguistic services, respite care for caregivers of people with HIV/AIDS, referrals for health care and other support services, case management, and substance abuse residential services. Grantees are required to spend at least 75 percent of their Part A grant funds allocated for services on core medical services and no more than 25 percent on support services. The RWHAP Part B grantee is the Florida Department of Health, HIV/AIDS Section, Patient Care Services. The Part B Consortia are distributed throughout Florida in HIV/AIDS service regions coordinated through fourteen lead agencies. Additional Part B services include the AIDS Drug Assistance Program (ADAP) and the AIDS Insurance Continuation Program. In fiscal year , ADAP was funded for the state of Florida at $92,174,926 with 22,988 clients served. Qualification criteria include being HIV+, an income 400% below Federal Poverty Level (less than $38,013 for 1-person household), being uninsured/lacking prescription drug coverage, and not confined to hospital, nursing home or, correctional facility. There are twenty-one RWHAP Part C clinics that provide comprehensive primary health care in an outpatient setting for people living with HIV disease. Six Part D grantees provide family-centered care involving outpatient or ambulatory care for women, infants, children, and youth with HIV/AIDS. Dental reimbursement is provided to the University of Miami and Nova Southeastern University. DRAFT Integrated HIV Prevention and Patient Care Plan 1

55 Prevention Funding Snapshot-Will include most current and narrative to support the way funding is allocated or distributed. Other sources of funding include funds from the State of Florida General Revenue account, the CDC Partnership for Care, Housing Opportunities for Person with AIDS (HOPWA), Surveillance Core, the Medical Monitoring Project, Behavioral Surveillance, and private /pharmaceutical funding. Local area consortia work to ensure that there is adequate collaboration between Ryan White Parts A and B through their use of Resource Prioritization and Allocation Recommendations Committee (RPARC). This committee is responsible for developing recommendations for the funding prioritization and allocation process. They work in close coordination with staff to assure that this process reflects the findings of the needs assessment. They also closely monitor spending so that necessary adjustments can be made so that needed services can be provided. Ryan White and the AIDS Drug Assistance Program have two missions. They help people with HIV who cannot get affordable health insurance pay for healthcare services. They also help boost the coverage available to people with HIV through their existing insurance, whether private, job-related, Medicaid or Medicare, by covering additional services or assisting with copays and cost sharing. Under the Affordable Care Act, there are new options for people with HIV to obtain insurance coverage that they have not had before, including purchasing coverage in the health insurance marketplace and expanded Medicaid. ( During the most recent enrollment period ending January 31, 2016, there were over 3,100 clients enrolled statewide. Program staff worked to transition more than 1,000 clients into the marketplace this year alone. DRAFT Integrated HIV Prevention and Patient Care Plan 2

56 Needed Resources According to the American Academy of HIV Medicine (AAHIVM), the current U.S. HIV medical workforce is largely composed of the first generation of HIV medical providers who entered the field more than 20 years ago. As a result, the HIV care system faces a serious crisis in care capacity as these clinicians retire without qualified recruits to take their place. In Florida, we work to mitigate this issue by enlisting the help of the HRSAfunded AIDS Education and Training Centers (AETCs) to build capacity for medical providers through education, consultation, and mentoring. The efforts alone, however, will not solve the workforce shortage. Each local consortium, and all of the participating member agencies, assess local needs and assure that resources are delivered based on those criteria. As service delivery data becomes more available, local areas use this information to eliminate redundant services, prioritize core service over support services, and address short-falls. In instances where there is a short-fall in funding to cover a needed service area, the consortia meet to discuss options. Often, funds are shifted from underutilized services or member agencies seek private funding to ensure uninterrupted services. Fund allocation is executed in a manner designed to have the greatest positive impact on the HIV Care Continuum. DRAFT Integrated HIV Prevention and Patient Care Plan 3

57 D. Assessing Needs, Gaps and Barriers The purpose of the integrated plan needs assessment analysis is to further examine the statewide 2013 Patient Care Anonymous Client Needs Assessment Survey and the 2014 HIV Prevention Provider Survey. The findings will be combined by detailing the prevention and care service needs, gaps, and barriers of persons at higher risk for HIV and People Living with HIV (PLWH) (diagnosed and undiagnosed) along the HIV Care Continuum. Historically, Florida has conducted independent Needs Assessment processes by following the guidance set forth respectively by the Health Resources and Services Administration (HRSA) and the Centers for Disease Control and Prevention (CDC). However, in June 2015, HRSA and CDC collaborated and released guidance that outlined the required submission of an integrated statewide care and prevention plan. Therefore, considering the limited timeframe available to conduct a thorough needs assessment process under the integrated plan guidance, it was agreed to use the previous patient care client survey analysis, the prevention provider survey analysis, and additional statewide data gathering strategies to include in the overall integrated plan needs assessment analysis. Background on 2013 Patient Care Anonymous Client Needs Assessment Survey The Florida Department of Health (FDOH), HIV/AIDS Section, recognized the need for consistent reporting within the state and created a standardized data collection protocol and needs assessment survey for PLWH. In 2013, the survey was updated with the primary focus being to determine met and unmet service needs in Florida for PLWH. As such, the survey was not limited to individuals currently served by the Ryan White Program. The survey of PLWH, which is only one component of the Needs Assessment process, examines the HIV-related service needs, gaps in service, and barriers from a consumer perspective. Background on 2014 HIV Prevention Provider Survey In December 2013, the Prevention Planning Group (PPG) Needs Assessment Committee was charged with reviewing and providing feedback on the 2010 draft provider needs assessment questionnaire and the 2013 Patient Care Anonymous Client Needs Assessment Implementation Guidelines. The PPG Needs Assessment Committee reviewed the 2010 provider tool question-byquestion and incorporated the suggested edits into the instrument. The original deadline for distribution of the survey was the end of January However, once the edits were made to the survey and the survey was finalized, it was agreed that there would be a pilot launch to a few areas first to ensure responses were coming in and there were no concerns with the survey questions. The goal was to work with the Early Intervention Coordinators (EICs) to distribute the survey to their local areas to pilot test the survey and then once the DOH could interpret their data, then they could widely distribute the survey. The revised timeline was to complete the pilot test results review by the end of January and then target mid-february to widely distribute the survey. DRAFT Integrated HIV Prevention and Patient Care Plan 4

58 Due to competing priorities, the survey was not finalized or approved for distribution until July The timeline for the survey was July 30, 2014 to September 30, 2014, including a 60-day response period, and a 30-day check-in to see who was completing it, and to follow-up with reminders. The HIV Prevention Provider Survey was conducted to identify needs and service gaps related to the delivery of HIV prevention services in Florida. The results of the survey help the Prevention Program better understand the prevention needs for those at risk for HIV. Process Methodology of 2013 Patient Care Anonymous Client Needs Assessment Survey The 2013 Patient Care Anonymous Client Needs Assessment Survey was administered in a variety of different ways, with some counties using multiple strategies. A standardized survey tool consisting of 45 items and multiple-choice responses was developed to assess service and other gaps from consumers within HIV/AIDS patient care systems throughout Florida. The tool was largely administered via the Internet and available in three languages (English, Spanish and Creole). Paper surveys were made available and local areas were able to customize the standardized tool by reordering or locally branding the survey, but were not allowed to modify the questions or question choices. Since the survey was not limited to individuals currently served by the Ryan White Program and it was not possible to compute response rates, it is important to note that more than 6,700 individuals completed the survey. Methodology of 2014 HIV Prevention Provider SurveyFrom early January 2014 to mid-june 2014, the Prevention Planning Group Needs Assessment Committee worked closely with the FDOH to determine the protocol for implementation of the 2014 Prevention Provider Survey. The following items were discussed during monthly conference calls: Establish regional targets for the number of the surveys that they wanted to gather from providers; o Where the survey would be distributed o Targeted list of prevention or testing providers per area o Targeted number of responses per area Focus distribution of the survey to providers engaged in High Impact Prevention activities, including prevention for positives; Include a more broad dissemination than just the state s funded providers; Review, edit and finalize the Prevention Provider Survey Develop a distribution plan for the survey-where and when Timeline for process In July 2014, The AIDS Institute, on behalf of the FDOH HIV/AIDS Section, widely distributed the survey to individuals who were providers of HIV-prevention related services in Florida. The distribution plan included the Early Intervention Consultants (EICs), HIV/AIDS Program Coordinators (HAPCs), Prevention Training Coordinators DRAFT Integrated HIV Prevention and Patient Care Plan 5

59 (PTCs), Minority AIDS Coordinators (MACs), and other prevention service providers as widely as possible. Surveys were sent to organizations, with directions that reflected the possible inclusion of multiple respondents from a given organization. The goal for respondents was 100. This and the goal were well exceeded with a total of 398 individuals from at least 96 agencies submitting responses. Data Collection 2013 Patient Care Anonymous Client Needs Assessment Survey Implementation strategies for the 2013 Patient Care Anonymous Client Needs Assessment Survey were broad and included a comprehensive approach. For example, paper copies of the survey were provided to clients while they were waiting to see their case managers or the case managers worked with clients to complete the survey during appointments. Case managers called clients in outlying counties and asked if they would complete a survey and if the client agreed, a survey was mailed to them, sometimes with postage included. Staff personnel, but not specifically an individual s case manager, also called clients in outlying areas to complete surveys over the phone. Other organizational personnel were used so that clients would feel free to answer the questions openly and honestly. The same staff would meet with a client in an office to help complete the survey if the client needed assistance. The survey was administered through Survey Monkey and links were posted on social media sites with a brief description of the targeted population, its purpose, and deadlines for completion of the survey. Throughout the state, the Internet was used to reach additional persons living with HIV/AIDS. Data Collection 2014 HIV Prevention Provider Survey The HIV Prevention Provider Survey was developed and disseminated using Survey Monkey. The survey was open from July 30, 2014-September 30, In total there were 398 survey respondents. The survey consisted of 33 questions designed to gather information from providers about the types of HIV services provided statewide, access to services, coordination of HIV services, barriers to HIV services, and HIV service needs. Survey responses were analyzed and summarized through Survey Monkey and a summary of survey responses were compiled and reviewed by the PPG Needs Assessment Committee and Prevention Program staff. Strengths and Limitations 2013 Patient Care Anonymous Client Needs Assessment Survey With more than 6,700 individuals completing the 2013 Patient Care Anonymous Client Needs Assessment Survey, coverage was adequate for a straightforward descriptive analysis of the data to convey useful information, without applying tests of statistical significance. Major issues that emerged were cautiously assumed to be approximations of trends among the general PLWH population in the state. Limitations of the data The demographic profiles of the sample and all PLWH differed enough especially among females to suggest a non-representative sample of clients had been achieved. Clients were self-selected for survey participation. Next time, efforts should be made to DRAFT Integrated HIV Prevention and Patient Care Plan 6

60 more systematically sample eligible individuals to produce a more representative sample, whose characteristics, knowledge, attitudes, and behaviors could then be reliably compared from one survey cycle to the next. Responses were subjective and subject to respondent biases, including recall and social desirability of answers to sensitive questions. However, this would be the case even if a randomized survey had been conducted. To enable better generalization to the overall PLWH population will require a different study design and consume more resources, but the cost-effective benefits in achieving the survey goals and objectives should outweigh the drawbacks. Finally, the survey period was April 1, 2013 through May 31, This was a shortened period of time and thus spanned with a smaller number of respondents than previous surveys. The timeframe was shortened because most planning areas needed the completed survey analysis processed prior to the submission of grant applications. Strengths and Limitations 2014 HIV Prevention Provider Survey The HIV Prevention Provider survey was 16 pages long, with 33 questions. For some survey items, there were as many as 17 sub-questions. The number of responses to questions ranged from about 200 to 396. Responses tended to decline from beginning to end, perhaps due to respondent fatigue, reflecting a limitation of the data. Limitations of the data The chief limitation of the provider survey was the design and distribution of the survey instrument. It was not aimed at a single, knowledgeable respondent from each agency. Definitive descriptions of the agencies could therefore not be obtained. Because of multiple respondents from most agencies, a meaningful analysis could not be conducted for sections 2 (agency characteristics), 3 (target populations served), 4 (agency funding and services provided), and 6 (barriers to HIV/AIDS services). Respondents were self-selected, and are a non-representative cross-section of a nonrandom selection of HIV prevention-related agencies. There were several questions that were ambiguously stated, with a potential for misinterpreting the findings. The length of the survey and numerous subsections to certain questions might have limited responses due to respondent fatigue, especially as the questionnaire progressed. The next time a provider needs assessment survey is conducted, it should be limited to one identified representative of each agency included in the survey. Definition In the HIV Prevention Provider Survey, provider is defined as an individual who provides HIV-related prevention services, regardless of their organizational affiliation. In this case there may be multiple providers from the same organization. Comment None of the providers represents the agency over the others. Thus, we could not analyze data from certain survey items that required a response from a single, knowledgeable representative of each agency having one or more respondents. All questions in 4 of the 8 sections of the survey instrument fell in this non-applicable category, i.e., sections 2 (agency characteristics), 3 (target populations served), 4 (agency funding and DRAFT Integrated HIV Prevention and Patient Care Plan 7

61 services provided), and 6 (barriers to HIV/AIDS services). Section 7 is not analyzable by area, due to very small cell sizes (unmet need of HIV prevention services), where the question was, In your opinion, what are the three most important unmet needs for HIV prevention services in your area? With one being the greatest unmet need. On the other hand, provider could have been defined as a single organization that provides HIV-related prevention service, and the survey would have been completed by one knowledgeable staff speaking on behalf of the organization. The advantage of this approach is that a single profile of each organization would have emerged from the one respondent who represented that organization. An advantage of the current study design is that a profile emerges of characteristics of all respondents, regardless of how many belong to a given organization, which are derived from the responses to most of 3 of the 8 sections, i.e. sections 1 (respondents demographics), 5 (provider knowledge, beliefs, and practices), and 8 (technical assistance and training needs). As an example of the consequences of multiple respondents from some organizations, there were 137 respondents who indicated they were from CHD clinics. If there were more than one person from a clinic, they might provide different or conflicting information about the nature of their clinic. Key participants A great number of individuals are involved in the needs assessment process: those who administered the surveys, those who conducted the statewide community engagement sessions, and those who conducted the town hall meetings. In addition, there were clients, consumers, statewide planning group members, other key stakeholders (not limited to Department of Health employees), patient care and prevention planning group representatives or alternates, community-based organizations, faith-based representatives, healthcare providers, consumers, persons living with HIV, and community advocates. Findings Characteristics of the Respondents Among males, the distributions of respondents by race/ethnicity were quite similar for PLWH and providers. Among 4,021 male respondents to the PLWH survey, 44% were non-hispanic white, 33% were non-hispanic black, 17% were Hispanic, and <4% were of other race/ethnicity. By comparison, among 116 male respondents to the HIV prevention provider survey, 43% were non-hispanic white, 29% were non-hispanic black, 21% were Hispanic, and <2% were of other race/ethnicity. Among females, 19% of 1,924 PLWH respondents were non-hispanic white, 58% were non-hispanic black, 14% were Hispanic, 6% were Haitian, and 3% were of other race/ethnicity. (Note: Haitian ethnicity was not routinely collected in the provider survey.) By comparison, among 222 female provider respondents, 51% were non-hispanic white, 36% were non-hispanic black, 8% were Hispanic, and <2% were of other race/ethnicity. DRAFT Integrated HIV Prevention and Patient Care Plan 8

62 According to primary role among the 338 providers responding to the questions about their primary role, the most common roles were program coordinator/manager (N=50); nurse or nurse practitioner (42); case manager (29); and health educator (25). These roles are also categorized by race/ethnicity and sex in Table 1. There was no corresponding question in the PLWH survey. Table 1. Primary Role of Provider Survey Respondents, by Race/ethnicity and sex, Florida, 2014 Non-Hispanic White Non-Hispanic Black Hispanic Asian American Indian/ Alaska Native Primary Role Male Female Male Female Male Female Male Female Male Female Male Female Advocate Board Member Case Manager Counselor Executive Director/Administrator Health Educator Nurse Nurse Practitioner Outreach Worker Peer Navigator/Educator Physician Prevention Specialist Program Coordinator/Manager Psychologist Receptionist/Secretary Response Social Worker Substance Abuse Professional Total *Not shown in table: 1 male Native Hawaiian/Pacific Islander Receptionist/Secretary; 1 transgender male (TGM) Asian Prevention Specialist; 1 TGM American Indian physician; 1 TGM American Indian Program Coordinator; 1 transgender female (TGF) American Indian Program Coordinator; 1 TGF American Indian Advocate. Other characteristics of the providers included the following: o Length of Time at Agency (391 respondents): Less than 1 year (9%); 1-4 years (25%); 5-9 years (28%); and 10 or more years (37%). o Currently Provide HIV Prevention services (397 respondents): Yes (79%); no (18%); unsure (3%). o Currently Provide Direct Medical Care (397 respondents): Yes (26%); no (72%); unsure (2%). If yes to direct medical care, 81 (27%) of 305 respondents consider themselves to be HIV specialists. Service Gaps There was some overlap of unmet need variables in both the PLWH survey and the provider survey. Six of 20 unmet service needs ( gaps ) of PLWH aligned with 6 of 26 perceived unmet prevention needs of providers. In the provider survey, the closer the average response was to 1, the greater the unmet need. The unmet need dimension was expressed as very high (rated as 1), high (rated as 2), or relatively low (rated as 3). o Peer Mentoring: In the PLWH survey, 50% of respondents indicated they did not receive peer mentoring services, but needed them. The number of PLWH indicating this unmet need (service gap size) was 1,030. In the provider survey, peer programs were viewed as high in the unmet need dimension (average score of 2.1). The number of providers rating peer programs was 105. o Substance Abuse Services: In the PLWH survey, 45% did not receive the DRAFT Integrated HIV Prevention and Patient Care Plan 9 Total Respondents

63 service, but needed it. The number of PLWH indicating a service gap was 657. In the provider survey, substance abuse services were perceived by respondents as a high unmet need (rated 1.9), with 96 respondents to the item. o Mental Health Services: In the PLWH survey, 33% did not receive the needed service. The service gap was 987. In the provider survey, the rating average was high (1.8), with 134 providers rating the service. o Health Education and Risk Reduction: In the PLWH survey, only 26% did not receive the service, but were in need of it. The number in the service gap was 712. In the provider survey, the rating average was also relatively low (2.3), with 58 respondents. o Treatment Adherence: In the PLWH survey, only 17% did not receive the needed service, with a service gap of 533. However, in contrast, in the provider survey, treatment adherence was rated very high in unmet need (1.3 average rating). Evidently, PLWH feel they are doing much better adherence-wise than providers. This discrepancy warrants further investigation. o Outreach: In the PLWH survey, 54% felt they did not receive the needed outreach service, with a service gap of 900. In the provider survey outreach was subdivided into field and online outreach. Both had high average unmet need ratings (2.2 and 2.1, respectively), with 39 and 58 respondents, respectively. DRAFT Integrated HIV Prevention and Patient Care Plan 10

64 DRAFT Integrated HIV Prevention and Patient Care Plan 11

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