Evaluation Report of the Community Development Block Grant (CDBG)-Funded HIV/AIDS Prevention Initiative

Evaluation Report of the Community Development Block Grant (CDBG)-Funded HIV/AIDS Prevention Initiative 2009-2010 Sonia Alemagno, Ph. D. (Kent State University) Peggy Shaffer-King, M.A. (Kent State University) William J. Miller, Ph.D. (Southeast Missouri State University) College of Public Health Kent State University 330.672.6501 salemagn@kent.edu eshaffe6@kent.edu wmiller@semo.edu October, 2010 1 P age

Evaluation of CDBG HIV Prevention Programs Annual Report July 2009 June 2010 Table of Contents Executive Summary.3 Introduction.4 General Report.5 Site.6 Race.7 Sexual Orientation.8 Gender.9 Education 10 Age..11 Income..12 Zip Codes.13 Knowledge Scale.15 HIV Risk Scale.16 HIV Risk by Knowledge.18 Impact of Programming on Knowledge and Risk.19 Results.19 Results by Site.20 Recommendations and Global Findings.20 Aggregate Pretest Report 22 Individual Site Reports AGAPE.26 AIDS Taskforce.77 Free Clinic.95 NEON.134 Proyecto Luz 141 Appendix I Client Survey Appendix II Training Survey 2 P age

EXECUTIVE SUMMARY In 2009, the Cleveland Department of Public Health (CDPH) continued to offer an intensive evaluation of the HIV prevention programs funded through Community Development Block Grant (CDBG) dollars that CDPH administers. In the 2009-2010 grant year, over 2,500 clients were reached with CDBG-funded HIV programming, and 1,203 of these completed the data collection instrument. The discrepancy between the number of clients served and the number of surveys collected is due to evaluation plans for some agencies and objectives not requiring data collection for some funded activities. Clients were part of the program at one of four agencies located throughout the city and each serving its own unique target populations. Given the variability in the type and reach of prevention programming conducted by the various sites, we did expect, as the data reflect, that some sites would reach many more clients than others. Since the contribution in terms of client numbers across sites is highly variable, any program-wide results should be interpreted with caution. However, aggregate data represents the collective efforts of the CDBG HIV prevention program to serve a target population and can be used for general planning purposes. As such, this report presents both aggregate and agency-specific reports. With regards to the general demographics of the clients served, we find that a majority are African- American (77%), heterosexual (83%), female (62%), with a high school diploma, GED, or less (71%), under 24 years old (70%), and with relatively low income (49% of households falling within 0-30% of Average Median Income for a household of the same size). Beyond demographics, clients are tested on their HIV knowledge and asked about potential risk behaviors. From these questions, a table is created to show the number of clients in each categorization, ranging from those individuals deemed the least at risk (High Knowledge, Lower Risk) to those at the highest risk (Low Knowledge, High Risk). In 2009, 5.9% of respondents fell in the least risk categorization while 6.3% of respondents were at the highest end. There were over 48% of respondents considered High Knowledge, Moderate Risk and just under a quarter were High Knowledge, High Risk. Since clients are often given a pre-test before programming and then administered a post-test, it is possible to measure the impact of the programming on knowledge and risk behavior. In regards to knowledge scores of individuals that were successfully tracked pre and post, the average pre-survey knowledge score was 7.53, while the average post-survey knowledge score was 7.68, indicating that most of these respondents were considered high knowledge prior to the programming and as an effect gained little. When looking at risk categorizations, the pre-test results had 10.2% classified as lower risk, 51.3% classified as moderate risk, and 38.6% classified as high risk. After programming, the number of lower risk respondents fell to 9.0%, the number of high risk individuals dropped to 37.0%, and the number of moderate risk respondents rose to 54.0%. 3 P age

INTRODUCTION The City of Cleveland Department of Public Health is authorized to administer Community Development Block Grant (CDBG) funds on the behalf of the United States Department of Housing and Urban Development (HUD), in conjunction with the City of Cleveland Department of Community Development. The purpose of the Community Development Block Grant funds allocated toward HIV/AIDS prevention is to directly impact the rate of transmission of HIV among Cleveland residents through providing education and intervention strategies to those at greatest risk. Providing significant resources specifically to those programs that target populations within the City of Cleveland ensures that the City s diverse populations are reached with messages that most effectively address their particular concerns. Consequently, programs seeking funding were required to target City of Cleveland residents in at least one of the following risk groups: High-Risk Heterosexual Women of Color Injection Drug Users Men who have Sex with Men HIV Prevention for Positives Youth-General Youth- LGBTQ Seniors General Public Information The focus of the CDBG HIV prevention funds is on prevention strategies that utilize innovative methods to effectively reach target populations. Programs requesting funding were also required to demonstrate their effectiveness in successfully meeting the complex needs of the target populations. Additionally, given the increase in new HIV infections, the fact that the epidemic has changed due to new therapies, scientific advances, new community attitudes, and beliefs, agencies were encouraged to create interventions that meet these challenging times and were required to show: An indication of evidence-based effectiveness, A commitment to innovation, and A willingness to create the types of programs and services that have made Cleveland a leader in the HIV prevention effort both nationally and worldwide. To that end awards were only granted to agencies: To support new programs which pilot innovative methods of HIV/AIDS prevention; To support or expand existing programs that have a demonstrated record of success; or To extend projects funded through previous CDBG grants that have successfully met their evaluation objectives. 4 P age

In 2009, the Cleveland Department of Public Health (CDPH) continued to offer an intensive evaluation of the HIV prevention programs funded through Community Development Block Grant (CDBG) dollars that CDPH administers. In order to maximize the impact and value of the evaluation, it was designed to span two years and to incorporate extensive technical assistance for the community agencies providing the HIV prevention programming and collecting the evaluation data. The Institute for Health and Social Policy (IHSP) at The University of Akron was contracted to design and conduct the evaluation, in partnership with CDPH and AFC, and provide technical assistance. The first year of the evaluation, July 2007-June 2008, focused heavily on 1) establishing measurable objectives for each goal of the prevention programs, and 2) designing and implementing a standard data collection instrument to be used across all funded programs focused on documenting the HIV knowledge, HIV risk factors, and demographic information for all clients served by the CDBG-funded HIV prevention programs. It should be noted that several of the funded programs engaged in a variety of prevention activities so the evaluators worked to help specify prevention goals for each of these activities. Year one results are available online at: http://www.clevelandhealth.org/health/hiv- AIDS/Publications.html. Ultimately, results from the year one analysis demonstrated that many clients served under the program do not report the risk factors we attempt to examine. This may be due to true lower risk or reluctance to report. In terms of knowledge, the results did indicate that the majority of clients served had high HIV knowledge of the items included in the knowledge scale. This was thought to potentially demonstrate the historic focus of the overall program on health education and the relative success within these programs to address knowledge gaps. When moving to year two, a finalized instrument was utilized by all agencies the entire year. Consequently, all data is now based on the same measures and will allow for a fuller and more valid dataset. Second, each of the eight agencies had to have objectives (formulated during meetings between the agency staff, CDPH, and evaluators) that involved follow-up data being collected to actually allow for the measuring of the effects of the intervention. The web-based reporting system continued to be used and data was collected by each agency and then picked up monthly by IHSP staff to be scanned. Regular interaction occurred between the agencies, evaluators, City of Cleveland, and AFC. The agencies also performed well during an unexpected transition as the evaluators (Dr. Sonia Alemagno and Peggy Shaffer-King) moved from IHSP to the Institution for the Study and Prevention of Violence at Kent State University. In year three, agencies were familiar at the beginning with the finalized instrument which should continue to offer us a more full and valid dataset. As with year two, all agencies were required to have objectives that involved follow-up data collection in order to permit a measure of the effect of programming on knowledge and risk. Agencies continued to utilize the web-based reporting system; the system was adjusted to include the opportunity for agencies to report free-response answers regarding activity, progress, barriers, and recommendations that supplement their data for each month. This addition has allowed the evaluators the opportunity to assess actions being taken by agencies to assure goals are met and to begin determining common barriers to implementing these programs both within and across agencies. As with previous years, regular interaction continued between agencies, evaluators, and the City of Cleveland. 5 P age

DEMOGRAPHICS OF CLIENTS REACHED In the 2009-2010 grant year, over 2,500 clients were reached with CDBG-funded HIV programming, and 1,203 of these completed the data collection instrument. The discrepancy between the number of clients served and the number of surveys collected is due to evaluation plans for some agencies and objectives not requiring data collection for some funded activities. The table below presents detailed information about those who completed the survey. Site Frequency Percent AGAPE 122 10.1 Free Clinic 210 17.5 NEON 600 49.9 Proyecto Luz 271 22.5 TOTAL 1203 100.0 This data largely demonstrates a substantial decrease from last year s report (and even the 2007-2008 report). Last year the report saw 3,353 individuals take pre-surveys while the prior year witnessed 2,689. Three agencies experienced losses in instruments collected while one agency saw an approximate 20% gain. It should be noted, however, that overall the program worked with three fewer agencies than in previous years. The three agencies not participating in 2009-2010 accounted for over 50% of all pre-survey responses in 2008-2009. As a result, fewer respondents were expected this year. Given the variability in the type and reach of prevention programming conducted by the various sites, we did expect, as the data reflect, that some sites would reach many more clients than others. Since the contribution in terms of client numbers across sites is highly variable, any program-wide results should be interpreted with caution. However, aggregate data represents the collective efforts of the CDBG HIV prevention program to serve a target population and can be used for general planning purposes. A full aggregate report is available starting on page 22. 6 P age

The annual demographic profile is presented below, including race 1, sexual orientation, gender, educational level, and age. As reported below, we also collected zip code data from clients to assess the geographic reach of the programs. Race Frequency Percent Black-African American 869 77.1 White 178 15.8 Other Multi Racial 50 4.4 Black-African American & White 19 1.7 American Indian- Alaskan Native & Black 7 0.6 American Indian-Alaskan Native 2 0.2 Asian 2 0.2 Total 1127 100.0 The race numbers indicate a continuation of a trend that emerged during the 2008-2009 reporting period. We see a larger percentage of Black-African Americans and a smaller percentage of all other racial groups. Each year of the data has indicated an increase of 8% in Black-African American respondents. This shows more efforts being placed on working with African-Americans which is welcomed given that Black-African Americans typically represent a previously identified higher risk population for transmitting HIV. It should also be noted that 11.1% of respondents (128) are of Hispanic/Latino descent. 1 Definitions of racial categories were dictated by federal government H.U.D. race reporting requirements. 7 P age

Given the potential complexities associated with identifying sexual orientation using the data provided by survey respondents, we have chosen to present a standard cross-tabulation to show verbatim identifications of each respondent. The complexity arises, for example, from having to label the orientation of a trans male. One could utilize an identity or behavior-based definition to determine sexual orientation in such a case, consequently meaning that a trans male that has sex with males could be identified as hetero- or homosexual based on the definition used. Sexual Orientation (n = 1136) Male Female Transgender (Male to Female) Transgender (Female to Male) Sex with Men 38 (3.3%) 601 (52.9%) 0 (.0%) 0 (.0%) Sex with Women 347 (30.5%) 27 (2.4%) 3 (.3%) 0 (.0%) Sex with Both 3 (.3%) 28 (2.5%) 0 (.0%) 0 (.0%) Never had Sex 29 (2.6%) 60 (5.3%) 0 (.0%) 0 (.0%) Compared to last year s sexual orientation demographics, we have a significantly smaller percentage of homosexual and bisexual respondents. Overall, we see a drop of approximately 8 percentage points. Likewise, we have far fewer transgendered individuals in our baseline survey pool. 8 P age

Gender Frequency Percent Female 722 62.2 Male 435 37.5 Transgender Male to Female 3.3 Transgender Female to Male 0.0 Total 1160 100.0 When comparing the gender breakdown in 2009-2010 to 2008-2009, we see a significant drop in the number of transgendered respondents. After seeing a move toward more gender equality from 2007-2008 to 2008-2009, the 2009-2010 data shows a higher percentage of females than males being included in the baseline. Further, we should note that 69.4% of respondents claimed that they lived in households headed by females. 9 P age

Education Frequency Percent Less than a high school diploma 442 38.4 High school diploma or GED 377 32.8 Some college 215 18.7 College degree 93 8.1 More than a college degree 23 2.0 Total 1150 100.0 Overall, the data collected in 2009-2010 describes a more polarized population when examining the educational attainments of respondents. Building on trends observed in 2008-2009, we see more respondents with less than a high school diploma and also more respondents with a college degree than in previous years. 10 P age

Age Frequency Percent 18 and under 444 38.2 19-24 370 31.8 25-29 84 7.2 30-39 98 8.4 40-49 78 6.7 50-59 61 5.2 60 and above 27 2.3 Total 1162 100.0 Continuing with trends that emerged in previous years of the data, we find almost a 10% increase in those 18 and under and those between 19 and 24. For all age groups between 25 and 59, we see roughly a 5% drop. As compared to previous years of data, the current round skews significantly toward younger individuals. 11 P age

For income, respondents are asked to select a letter corresponding to the following table which asks them to utilize the size of their household and their annual income. Household Size Annual Income You You + 1 You + 2 You + 3 You + 4 or more A low to 0 0 0 0 0 Maximum $12,599 $14,399 $16,199 $17,999 $19,449 B low to 12,600 14,400 16,200 18,000 19,450 Maximum 20,999 23,999 26,999 29,999 32,399 C low to 21,000 24,000 27,000 30,000 32,400 Maximum 33,599 38,399 43,199 47,999 51,849 D 33,600+ 38,400+ 43,200+ 48,000+ 51,850+ Household Income Range Frequency Percent 0-30% of Average Median Income 549 48.5 30.1-50% 266 23.5 50.1-80% 200 17.7 > 80.1% 116 10.3 Total 1131 100.0 When comparing the income breakdown for the current year s data with that from 2008-2009, we see relatively similar numbers within each category. Our most noticeable differences are a 2% decrease in the 0-30% of Average Median Income category and a 1.4% increase in those in the highest income bracket. 12 P age

Zip Code ZIP Freq. % ZIP Freq. % ZIP Freq. % 43227 1.1 44113 19 1.6 44145 1.1 43615 1.1 44114 6.5 44146 15 1.2 44001 1.1 44115 14 1.2 44147 1.1 44003 1.1 44116 1.1 44152 2.2 44011 1.1 44117 9.7 44162 1.1 44012 2.2 44118 21 1.7 44164 2.2 44022 1.1 44119 10.8 44169 1.1 44024 1.1 44120 50 4.2 44170 1.1 44055 1.1 44121 23 1.9 44182 1.1 44056 1.1 44122 9.7 44186 1.1 44070 6.5 44123 13 1.1 44188 1.1 44077 1.1 44124 6.5 44216 1.1 44092 1.1 44125 19 1.6 44223 1.1 44094 1.1 44126 2.2 44241 2.2 44095 1.1 44127 9.7 44266 1.1 44100 1.1 44128 62 5.2 44306 1.1 44101 2.2 44129 3.2 44312 1.1 44102 109 9.1 44130 5.4 44366 1.1 44103 101 8.4 44132 10.8 44408 1.1 44104 72 6.0 44133 2.2 44413 1.1 44105 101 8.4 44134 3.2 44515 1.1 44106 70 5.8 44135 13 1.1 44602 2.2 44107 12 1.0 44136 1.1 44611 1.1 44108 95 7.9 44137 21 1.7 44801 1.1 44109 48 4.0 44139 1.1 N.P.A. 27 2.2 44110 30 2.5 44142 1.1 Missing 6.5 44111 60 5.0 44143 1.1 44112 57 4.7 44144 20 1.7 Overall, twenty-seven respondents (2.2) reported having no permanent address and consequently have no zip code. Second, out of the 100 plus zip codes reported by clients that are served by CDBG projects, 16 account for over 75% of the clients served. These zip codes represent Cleveland proper and its adjacent communities. This is consistent with data from 2007-2008 and 2008-2009. 13 P age

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CLIENTS HIV KNOWLEDGE AND RISK In order to examine the key concepts of HIV knowledge and HIV risk, we calculated two new scale variables. The knowledge and risk scales were not calculated for The AIDS Taskforce of Greater Cleveland because this agency is exclusively involved in a training program for professionals. The knowledge scale variable was based on 10 knowledge questions. Therefore, a client s knowledge score could range from 0-10, with 0 being the lowest knowledge and 10 being the highest. Aggregate results showed that the majority of clients served this year across programs had high or relatively high knowledge. In fact, just fewer than 70% of those reached in the program scored a 7 or higher on the HIV knowledge scale. Over 40% scored 9 or 10 out of 10. This suggests that spending a significant portion of time during these HIV prevention programs on key HIV knowledge may not be an efficient effort, and time could be better used to address other knowledge issues or behavioral risk. Such findings remain consistent with data from 2007-2008 and 2008-2009. In fact, the current year s data suggests that respondents are even more educated at the time of pretesting than in previous years. Knowledge Cumulative Frequency Percent Score Percent Missing 121 10.1 X 0 35 2.9 3.2 1 11.9 4.3 2 12 1.0 5.4 3 17 1.4 6.9 4 38 3.2 10.4 5 50 4.2 15.1 6 90 7.5 23.4 7 118 9.8 34.3 8 194 16.1 52.2 9 317 26.4 81.5 10 200 16.6 100.0 Total 1203 100.0 15 P age

The risk score was based on a series of behavior questions (pertaining to sexual behavior and drug use patterns). Ultimately, we calculated a score intended to separate respondents into three groups: high risk, lower risk, and moderate risk. In order to be considered high risk, respondents had to respond with one (1) or more of the following four (4) responses: 1) Responding that they have had 5 or more sexual partners in the last 30 days 2) Responding that most of their sexual encounters take place in bath houses, adult bookstores, sex parties, massage parlors, or spas 3) Responding that they have injected or shot drugs to get high (by drug we mean any drug that a doctor or pharmacist has not given the respondent) 4) Responding that they never use a condom or they had to respond that their partners were HIV positive and that during sex they either never or only sometimes used a condom. In order to be considered lower risk, respondents had to respond according to ALL of the following responses: 1) Responding that they have had no sexual partners in the last 30 days 2) Responding that they do not believe that their sexual partner(s) have had any other sexual partners in the past 30 days or they have not had sex in the last 30 days. 3) Responding that they have never used non-prescription drugs or alcohol before or during sex in the last 30 days. 4) Responding that they have never used drugs to get high in the last 30 days. 5) Responding that they have not injected or shot drugs to get high (by drug we mean any drug that a doctor or pharmacist has not given the respondent) 6) Responding that they either do not have sex or always ask about a partner s past sexual relationships before having sex with them. 7) Responding that they either do not have sex or always ask about a partner s use of drugs and steroids, including their use of needles, before having sex with them. 8) Responding that they either do not have sex or always use a condom. 9) Responding that they have never had an STD. 10) Responding that their sexual partner/s is/are not HIV positive. 11) Responding that they have never traded sex for money, drugs, or a place to stay. If respondents were not classified as high risk or lower risk, they fell into the moderate risk category. If individuals did not answer a necessary question, they did not have a risk score calculated. Examining the valid data percents (adjusted for missing data), we find that overall, over 30% of respondents are identified as being high risk for acquiring HIV, or if already HIV+ for transmitting HIV. Only 8% of respondents meet all the criteria set forth to qualify as being at lower risk. As one would expect, the majority of respondents (approximately 61%) fall into our moderate risk category. Compared to previous years, this demonstrates roughly ten percent fewer respondents that enter programming classified as high risk and just fewer than ten percent more in moderate risk. 16 P age

Risk Score Frequency Percent Lower Risk 81 8.1 Moderate Risk 612 61.1 High Risk 309 30.8 Total 1002 100.0 All Sites Scale N Mean Std. Deviation Std. Mean Knowledge 1082 7.63 2.384.072 Risk 1002 1.23.581.018 We conceptualize these scales into categories of knowledge grouped with categories of risk, based on the following conceptualization: Low Knowledge, High Risk (Our highest risk population) High Knowledge, High Risk Low Knowledge, Moderate Risk High Knowledge, Moderate Risk Low Knowledge, Lower Risk High Knowledge, Lower Risk (Our lowest risk population) Low knowledge was determined by answering between 0 to 6 questions correctly on the objective HIV knowledge scale. Based on this conceptualization and including only pre-test data, we find that the annual data shows that the overall program clients reached included only 59 clients at low knowledge and high risk (that is, 6.3% of the population reached by the program were in the highest overall risk category). This is a drop from 14.5% in 2008-2009 and 15.5% in 2007-2008. Given the new conceptualization, 17 P age

however, we find that our second-most populated category is those with high knowledge and high risk (23.4%); the same result was found in 2008-2009, although at a higher percentage. What this potentially suggests is that being knowledgeable of the threat of HIV is not serving as an adequate measure to prevent respondents from practicing high risk behaviors. This overall categorization allows for some general assessment of clients overall risk levels, but does possess some limitations. Consider the idea of a community viral load (which accounts for both the prevalence of HIV in a community and the degree to which those who are HIV+ have access to medical care which can lower their level of virus). This measure tells us that a client with moderate risk according to the scale may in fact be at high risk for acquiring HIV if the community viral load in her/his social network is high. In other words, someone at moderate risk in a community with a high viral load may be at more risk than an individual at high risk in a community with a low viral load. HIV Risk by Knowledge Number Percent Low Knowledge, High Risk 59 6.3 High Knowledge, High Risk 220 23.4 Low Knowledge, Moderate Risk 127 13.5 High Knowledge, Moderate Risk 459 48.8 Low Knowledge, Lower Risk 20 2.1 High Knowledge, Lower Risk 55 5.9 Total 940 100.0 18 P age

IMPACT OF PROGRAMMING ON KNOWLEDGE AND RISK In order to examine the change in knowledge and risk from the time respondents completed their initial survey to the time they received the intervention and completed the follow-up survey, we matched all respondents pre- and post-surveys according to the unique identification number provided by each agency for tracking purposes. After doing so, we were left with two hundred and fifty-four individuals that were able to be compared although not all respondents answered all questions in the risk and knowledge scales. Agencies were asked to have individuals complete a pre-test survey as they enter agency programming. The Cleveland Department of Public Health and the evaluators, Kent State University, worked with each agency to determine the appropriate follow up time frame. Post-test follow up ranged from thirty (30) days to three (3) months following the pre-test. In regards to knowledge scores of individuals that were successfully tracked pre and post, the average pre-survey knowledge score was 7.53, while the average post-survey knowledge score was 7.68, indicating that most of these respondents were considered high knowledge prior to the programming and as an effect gained little. Compared to last year, this shows both a larger programming effect and a high level of knowledge, overall. When looking at risk categorizations, the pre-test results had 10.2% classified as lower risk, 51.3% classified as moderate risk, and 38.6% classified as high risk. After programming, the number of lower risk respondents fell to 9.0%, the number of high risk individuals dropped to 37.0%, and the number of moderate risk respondents rose to 54.0%. Using a comparison of means test between pre and post scores, we fail to find any significant difference. However, we should note that the decrease in high risk individuals is a positive sign. Unfortunately, there is a corresponding decrease in the number of individuals that find themselves in the lower risk category. The data from 2008-2009 had shown the same gain in individuals that demonstrate lower risk but that year also demonstrated a subsequent decrease in high risk individuals after receiving programming. RESULTS Data for 2009-2010 demonstrates much of the same result as those from the previous year. Many clients served under this program do not report the risk factors that we examine. The retooled risk analysis method developed in year two was again used and more accurately matches responses to the risk analysis questions with likelihood of contracting HIV from stated behavior. We still have concerns regarding the willingness of respondents to report risk behaviors even with the anonymity of survey responses. With regards to knowledge, the results clearly show that the majority of clients served have high HIV knowledge of the items included in the knowledge scale. This may demonstrate the historic focus of the overall program on health education and the relative success within these programs of addressing the knowledge gap. Looking at specific questions, only two questions were correctly answered by fewer than 70% of those surveyed (whether natural skin condoms work better than latex at preventing the contraction of HIV and whether HIV can be transmitted through deep kissing). These questions have been regularly answered incorrectly in previous rounds of data analysis. A new trend related to specific knowledge questions is that less than 75% correctly answered that there is a vaccine that will prevent an individual from contracting HIV. Future 19 P age

trainings may want to be sure to clearly address these questions given the relatively lower levels of knowledge of them. As was stated in previous annual reports, there are still concerns regarding the high number of high knowledge, high risk respondents (although the number has dropped 8% from last year s report). Since they are clearly demonstrating the knowledge to understand how HIV is spread, programming that is designed to examine behavior change will likely be of more use to that population. Riskknowledge results vary for individual sites, but the aggregate data clearly demonstrates that CDBG agencies are reaching a substantial group of clients who are in the moderate risk category for contracting HIV. RESULTS BY SITE A cursory examination of the mean knowledge scale scores and mean risk categorizations by site shows that there is substantial variation in the risk levels of clients being served. Below is a breakdown of each individual site and their reports for the agency as a whole and by objective. These results could be used to provide technical assistance to sites on their client recruitment efforts and the ability to assure that clients are receiving programming that best fits their needs. RECOMMENDATIONS AND GLOBAL FINDINGS As in previous reports, we must begin by noting the willingness of community agencies to work with the evaluators to make the changes necessary to assure effective programming. They worked diligently to assure reachable, meaningful objectives, effective follow-ups, and proper client tracking. While agencies have been working toward evidence based or standardizes programs for the clients served with CDBG dollars, the current year assisted them further by asking them to provide evaluators with an assessment of their perceived barriers to fulfilling objectives every month. As we advance further into the program, it will be essential to utilize the perceived barriers when agencies, evaluators, and city officials meet to discuss future plans and objectives. Only by learning from these barriers and determining how to work within the given framework will we be able to assure that agencies are able to meet all objectives in the most efficient manner possible. Similar to previous reports, it is important to point out the vital role played by the personnel at the community agencies. Personnel changes in these smaller agencies had a significant impact on agencies as they tried to continue toward the completion of their objectives. Most of the agencies implemented their programs with only one or two staff and if the person in charge of the program left, data collection was often left up in the air until new staff could be hired and trained. While we witnessed fewer staff changes than in previous years of data collection, we still find it necessary to point out the time and effort put forth by all of our community agencies. The data indicates that like in previous years, most of the agencies were generally serving clients with relatively high knowledge and relatively moderate risk. Like in year 2, follow up data for year 3 shows that there is no statistically significant improvement in increasing knowledge or reducing risk for clients served although scores moved in the desired direction. During the first two years of this project each agency received multiple site visits. As part of those initial year one site visits, agencies were asked to participate in helping to develop a single instrument 20 P age

that would be used by all CDBG sites. It should always be noted that year one represented multiple survey instruments that reflected changes in question wording, placement, agency needs, etc. Beyond an agency s willingness to use a new instrument, each agency worked with the Cleveland Department of Health and the evaluators to develop agency specific objectives based on the proposals currently funded for year one of the evaluation. Again, it should be noted that this was a totally new approach for agencies regarding how agencies addressed the populations served with their CDBG dollars and how data needed to be collected. Once objectives were developed, site visits generally addressed issues around appropriately developing objective numbering systems that worked for the agency. This was an important step for agencies since they were now working toward specific objectives that addressed special populations with target numbers to reach. By the end of year one, a final instrument was completed and prepared for use in year two. Because the Cleveland Department of Public Health saw this as a two year commitment, we were then able to work with each agency to refine their objectives based on data from year one and move all agencies toward the collection of follow up data for at least some of their objectives in year two. As agencies became more familiar with numbering and survey administration, technical support began addressing issues of follow up. During the course of year two, most technical support revolved around learning and supporting the development of follow up techniques that were appropriate for each agency and each objective within the agency. For many agencies this was a developmental process of trying something, learning from what worked and did not work, and then improving on and/or changing strategies to find something that worked better. In year three, as previously discussed, most of the technological advances dealt with making it possible to provide additional information to evaluators that was not available in previous years of data collection. This information including activity, progress, barriers to completion, and recommendations will provide helpful tips as agencies plan future programming. From the first year to present, agencies have been able to use collected data to better articulate objectives that reflect populations in-need of HIV education and awareness. In year two, agencies did a better job of assuring that they completed pretests but struggled with post-test follow up collection. In year three, we found agencies devoting more energy to collecting follow up data and having variable success in doing so. In future years, we will want to continue assuring that we strive to achieve as many follow-up surveys as possible. 21 P age

Survey Item Analysis CDBG: Year Two OVERALL Client Pretest Report Facility AGAPE 122 Free Clinic 210 NEON 600 Proyecto Luz 271 Demographic information is reported on pp. 6-13. Risk Questions How many sexual partners have you had in the last 30 days? (n = 1180) 5 or more 6.1% 2-4 14.9% 1 52.8% None 25.9% Do you think your sexual partner(s) have had any sexual partners other than you in the last 30 days? (n = 1203) Yes 26.4% No 52.5% No sex in the last 30 days 21.2% Where do you have most of your sexual encounters (select one answer)? (n = 1169) In your or your partner s home 69.8% In bath houses, adult bookstores, sex parties, massage parlors, or spas 0.8% In hotel/motels rooms, cars, or bars 1.8% Someplace else 10.0% Not sexually active 17.6% How many times in the last 30 days, did you use non-prescription drugs or alcohol before or during sex? (n = 1182) 5 or more 7.2% 2-4 9.2% 1 8.0% Never 75.5% 22 P age

How many times in the last 30 days, did you use drugs to get high? (n = 1155) 5 or more 10.6% 2-4 5.2% 1 5.7% Never 78.5% Have you ever injected or shot drugs to get high (by drug we mean any drug that a doctor or pharmacist did not give to you)? (n = 1160) Yes 7.1% Before you have sex with someone, do you ask about their past sexual relationships? (n = 1154) Always 34.4% Sometimes 39.7% Never 12.7% Do not have sex 13.3% Do you ask sexual partners before you have sex about their use of drugs and steroids, including their use of needles? (n = 1145) Always 28.1% Sometimes 26.4% Never 31.7% Do not have sex 13.8% How often do you use a condom? (n = 1145) Always 26.6% Sometimes 42.8% Never 16.9% Do not have sex 13.8% Have you ever had an STD (such as gonorrhea, syphilis, Chlamydia, genital warts, or genital herpes)? (n = 1153) Yes 30.8% No 64.1% Don t know 5.1% When was the last time you had an HIV test? (n = 1144) In the past few weeks 8.7% In the past few months 20.9% In the past year 16.9% More than a year ago 19.2% Never 34.3% 23 P age

Are you HIV positive? (n = 1154) Yes 0.9% No 84.3% Don t know 14.8% Is/Are your sexual partner/s HIV positive? (n = 1137) Yes 0.5% No 80.5% Don t know 19.0% Have you ever traded sex for money, drugs, or a place to stay? (n = 1144) Yes 7.5% No 90.8% Don t know 1.7% Risk Scores (n = 1002) Lower Risk 8.1% Moderate Risk 61.1% High Risk 30.8% Knowledge Questions Percent Correct Pulling out the penis before a man climaxes/cums keeps a woman from getting HIV during sex. (n = 1161) 83.6% A woman can get HIV if she has anal sex with a man. (n = 1156) 82.3% Showering or washing one s genitals/private parts after sex keeps a persona from getting HIV. (n = 1154) 85.1% There is a vaccine that can stop adults from getting HIV. (n = 1156) 74.5% People are likely to get HIV by deep kissing, putting their tongue in their partner s mouth, if their partner has HIV. (n = 1153) 49.4% A woman cannot get HIV if she has sex during her period. (n = 1157) 75.8% A natural skin condom works better against HIV than a latex condom does. (n = 1154) 66.1% Having sex with more than one partner can increase a person s chance of being infected with HIV. (n = 1156) 85.4% A person can get HIV from oral sex. (n = 1152) 79.3% Using Vaseline or baby oil with condoms lowers the chance of getting HIV. (n = 1153) 76.8% Knowledge Scores (Maximum score of 10) (n = 1082) Range 0-10 Average 7.63 Knowledge Scores (n = 1203) Score Frequency % C % Score Frequency % C % Score Frequency % C % Miss 121 10.1 X 3 17 1.6 6.9 7 118 10.9 34.3 0 35 3.2 3.2 4 38 3.5 10.4 8 194 17.9 52.2 1 11.9 4.3 5 50 4.6 15.1 9 317 29.3 81.5 2 12 1.0 5.4 6 90 8.3 23.4 10 200 18.5 100.0 24 P age

HIV Risk by Knowledge Number Percent High Risk-Low Knowledge 59 6.3 High Risk-High Knowledge 220 23.4 Moderate Risk-Low Knowledge 127 13.5 Moderate Risk-High Knowledge 459 48.8 Lower Risk-Low Knowledge 20 2.1 Lower Risk-High Knowledge 55 5.9 Total 940 100.0 Risk Scores Pre (n = 197) Post (n = 189) Lower Risk 10.2% Lower Risk 9.0% Moderate Risk 51.3% Moderate Risk 54.0% High Risk 38.6% High Risk 37.0% Knowledge Scores (Maximum score of 10) Pre (n = 207) 7.53 Post (n = 212) 7.68 25 P age

Agency Name: AGAPE Program (Antioch Development Corporation) Agency Address: 8869 Cedar Avenue, Cleveland, Ohio 44106 Program Name: The Faith-Based Circle of Care Project Target Population: African American Females, Aged 25-44 years Program Staff: Gena Austin, Program Manager Grant Amount: $40,000 Program Description: The Faith-Based Circle of Care Project is focused on creating active partnerships with six community-involved pastors and their congregations. AGAPE expects to raise awareness among African Americans who may not otherwise be reached. These faith-based congregations typically include large cohorts of heterosexual females aged 25-44, one of the largest populations at-risk for contracting HIV. The recruited congregations will become members of AGAPEs Faith Community Network, a consortium of urban churches in six City of Cleveland wards. Through their membership congregants will be dedicated to the prevention and containment of HIV/AIDS via education, lifestyle change and HIV testing within the African American community. Objective Actual Target % of Recruit 3 churches to become participants in the Circle of Care Project 3 total Three churches will be recruited to participate in the Circle of Care Project MOU will be completed by each 3 3 100 participating church Recruit and train 3 site coordinators 3 total Site coordinators will complete the pre/post test training surveys Site coordinators will 3 3 100 complete an HIV/STD curriculum Church congregants will complete HIV/STD Prevention sessions 60 total Congregation members will participate in HIV/STD educational curriculum All participants will complete the pre/post 36 60 72 test client surveys 2nd year churches (5) will sponsor 3 5 events during the year 3 total 5 second year churches will collaborate to sponsor 3 to 5 community HIV health and/or awareness events All participants of 11 3 367 the health/awareness events will complete pre-test client surveys Symposiums will be conducted at third year churches 60 total All participants will complete pre/post surveys & workshop evaluation 20 women will be recruited per symposium Decisions We Make 9 60 15 Workshop will be presented Quarterly meeting with site coordinators 4 total No pre/post test survey data collection required 4 4 100 Clients surveys from health/awareness events 106 60 177 26 P age

AGAPE has been successful in working toward their objectives in year three. Outside of the measurable survey responses, AGAPE has worked to recruit new churches to the Circle of Care project, recruited site coordinators at the new churches, helped second year churches begin developing events related to community HIV health and awareness events, held symposiums at third year churches, and also held meetings with all site coordinators to align projects. There are, however, barriers to implementation with some objectives. Looking at adding churches, recruitment is often hindered by the availability of someone at the church to take responsibility for the program. As a means to combat this potential barrier, AGAPE will be attempting to have smaller churches join together to share the responsibility of implementing the programs. Likewise, finding individuals to take over as site coordinators has proved to be a potential barrier. With regards to having congregations complete HIV/STD prevention sessions, AGAPE has found that church people do not like completing surveys that are sexual in nature and are working to find ways for respondents to feel more secure in their decision to participate. Third year symposiums have been difficult to schedule given the full schedules of most churches. This was ultimately their weakest objective with regards to accomplishment. Getting people to change events or add another has proven to be problematic. Quarterly meetings have been difficult to schedule. Lastly, the health and awareness events (including Langston Hughes, Lion of Judah, Ecumenical HIV Task Force, First Ladies Breakfast, and Golden Ciphers Training) have gone well, but people are still reluctant to participate out of fear that the survey may be linked back to them. As such, AGAPE is considering making it possible for respondents to drop their completed surveys anonymously into envelopes during events. Overall, AGAPE is facing barriers related to time and responsibility. Busy schedules at churches and the time commitment to running this program have both been noted as barriers to implementation and AGAPE has identified ways to help share the burden for churches. They have further been proactive in attempting to come up with mechanisms to alleviate citizen concern about surveys being linked back to the respondent. Results Summary: Data indicate that AGAPE s Circle of Care program continues to successfully reach heterosexual, African-American women its target audience. With regards to age, they could look for improvement in reaching individuals between 25 and 44 as presently that age range accounts for only 48.6% of their surveys. Attendees of the church programs demonstrate relatively high knowledge and low risk, with roughly a third never being tested for HIV. Year three data shows a greater percentage of program attendees being high risk for contraction of HIV mainly due to a large number of respondents claiming to never use a condom. This fact may be due to the fact that almost 90% of those surveyed have either not had sex in the past 30 days or are in monogamous relationships. Post-surveys indicate fairly static numbers with regards to knowledge and risk. While not statistically significant, the analysis actually shows respondents measuring less knowledgeable in post-surveys. 27 P age

CDBG: Year Three Client Pretest Report Facility AGAPE 122 Demographics Are you of Hispanic or Latino descent? (n = 118) Yes 21.2% Race (check only one) (n = 104) White 12.5% Black-African American 81.7% Asian 1.0% American Indian-Alaskan Native 0.0% Native Hawaiian-Other Pacific Islander 0.0% Asian & White 0.0% Black-African American & White 1.9% American Indian-Alaskan Native & Black 2.9% Other Multi Racial 0.0% Gender (n = 118) Male 21.2% Female 78.8% Transgender Male to Female 0.0% Transgender Female to Male 0.0% Sexual Orientation (n = 115) Sex with Men Sex with Women Sex with Both Never Had Sex Male 2 (1.7%) 20 (17.4%) 0 (0.0%) 3 (2.6%) Female 83 (72.2%) 5 (4.3%) 2 (1.7%) 0 (0.0%) Transgender Male to Female 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) Transgender Female to Male 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) Education (check highest level) (n = 117) Less than high school diploma 7.7% High school diploma or GED 25.6% Some college 30.8% College degree 25.6% More than a college degree 10.3% 28 P age

Zip Code (n = 122) Zip Frequency % Zip Frequency % Zip Frequency % 44003 1.8 44111 10 8.2 44128 7 5.7 44070 1.8 44112 10 8.2 44130 1.8 44101 1.8 44115 1.8 44132 2 1.6 44102 8 6.6 44117 7 5.7 44135 7 5.7 44103 3 2.5 44119 1.8 44137 3 2.5 44104 2 1.6 44120 3 2.5 44144 6 4.9 44105 7 5.7 44121 6 4.9 44146 2 1.6 44106 3 2.5 44122 2 1.6 44169 1.8 44107 1.8 44123 1.8 47103 1.8 44108 2 1.6 44124 2 1.6 Missing 4 3.3 44109 6 4.9 44125 1.8 N.P.A. 3 2.5 44110 4 3.3 44126 2 1.6 Age (n = 119) 18 and under 3.4% 19-24 11.8% 25-29 9.2% 30-39 21.8% 40-49 17.6% 50-59 20.2% 60 and above 16.0% Is a female your head of household? (n = 118) Yes 61.9% Household income range (n = 119) 0-30% of Average Median Income 31.1% 30.1-50% 18.5% 50.1-80% 25.2% > 80.1% 25.2% Risk Questions How many sexual partners have you had in the last 30 days? (n = 117) 5 or more 1.7% 2-4 7.7% 1 51.3% None 36.8% 29 P age

Do you think your sexual partner(s) have had any sexual partners other than you in the last 30 days? (n = 97) Yes 9.3% No 67.0% No sex in the last 30 days 23.7% Where do you have most of your sexual encounters (select one answer)? (n = 113) In your or your partner s home 63.7% In bath houses, adult bookstores, sex parties, massage parlors, or spas 0.9% In hotel/motels rooms, cars, or bars 1.8% Someplace else 5.3% Not sexually active 28.3% How many times in the last 30 days, did you use non-prescription drugs or alcohol before or during sex? (n = 116) 5 or more 6.9% 2-4 5.2% 1 6.0% Never 81.9% How many times in the last 30 days, did you use drugs to get high? (n = 117) 5 or more 5.1% 2-4 2.6% 1 0.0% Never 92.3% Have you ever injected or shot drugs to get high (by drug we mean any drug that a doctor or pharmacist did not give to you)? (n = 119) Yes 1.7% Before you have sex with someone, do you ask about their past sexual relationships? (n = 113) Always 35.4% Sometimes 26.5% Never 17.7% Do not have sex 20.4% Do you ask sexual partners before you have sex about their use of drugs and steroids, including their use of needles? (n = 114) Always 28.9% Sometimes 18.4% Never 31.6% Do not have sex 21.1% 30 P age

How often do you use a condom? (n = 111) Always 16.2% Sometimes 27.9% Never 33.3% Do not have sex 22.5% Have you ever had an STD (such as gonorrhea, syphilis, Chlamydia, genital warts, or genital herpes)? (n = 115) Yes 27.3% No 70.7% Don t know 2.0% When was the last time you had an HIV test? (n = 113) In the past few weeks 3.5% In the past few months 14.2% In the past year 21.2% More than a year ago 27.4% Never 33.6% Are you HIV positive? (n = 117) Yes 0.9% No 83.8% Don t know 15.4% Is/Are your sexual partner/s HIV positive? (n = 108) Yes 0.9% No 87.0% Don t know 12.0% Have you ever traded sex for money, drugs, or a place to stay? (n = 114) Yes 7.0% No 92.1% Don t know 0.9% Risk Scores (n = 91) Lower Risk 13.2% Moderate Risk 41.8% High Risk 45.1% 31 P age

Knowledge Questions Percent Correct Pulling out the penis before a man climaxes/cums keeps a woman from getting HIV during sex. (n = 116) 82.8% A woman can get HIV if she has anal sex with a man. (n = 117) 78.6% Showering or washing one s genitals/private parts after sex keeps a persona from getting HIV. (n = 117) 90.6% There is a vaccine that can stop adults from getting HIV. (n = 118) 83.9% People are likely to get HIV by deep kissing, putting their tongue in their partner s mouth, if their partner has HIV. (n = 115) 56.5% A woman cannot get HIV if she has sex during her period. (n = 116) 77.6% A natural skin condom works better against HIV than a latex condom does. (n = 115) 71.3% Having sex with more than one partner can increase a person s chance of being infected with HIV. (n = 115) 82.6% A person can get HIV from oral sex. (n = 114) 71.1% Using Vaseline or baby oil with condoms lowers the chance of getting HIV. (n = 115) 82.6% Knowledge Scores (Maximum score of 10) (n = 104) Range 0-10 Average 7.79 Knowledge Scores (n = 104) Score Frequency % C % Score Frequency % C % Score Frequency % C % Miss 18 14.8 X 3 3 2.9 4.8 7 12 11.5 31.7 0 2 1.9 1.9 4 2 1.9 6.7 8 28 26.9 58.7 1 0 0.0 1.9 5 5 4.8 11.5 9 24 23.1 81.7 2 0 0.0 1.9 6 9 8.7 20.2 10 19 18.3 100.0 HIV Risk by Knowledge Number Percent High Risk-Low Knowledge 7 8.6 High Risk-High Knowledge 25 30.9 Moderate Risk-Low Knowledge 6 7.4 Moderate Risk-High Knowledge 32 39.5 Lower Risk- Low Knowledge 4 4.9 Lower Risk- High Knowledge 7 8.6 Total 81 100.0 Risk Scores Pre (n = 20) Post (n = 15) Lower Risk 20.0% Lower Risk 13.3% Moderate Risk 20.0% Moderate Risk 33.3% High Risk 60.0% High Risk 53.3% Knowledge Scores (Maximum score of 10) Pre (n = 19) 8.68 Post (n = 19) 7.95 CDBG: Year Three Client Pretest Objective Report 32 P age