LA HIV/AIDS Comprehensive Care Plan: 2004

DRAFT NOT FOR CITATION
PCH and County of Los Angeles December 2004

COUNTY OF LOS ANGELES

HIV/AIDS COMPREHENSIVE CARE PLAN

August 2002
Updated December 2004

COUNTY OF LOS ANGELES
HIV/AIDS COMPREHENSIVE CARE PLAN

Prepared for
The Los Angeles County Commission on HIV Health Services

December 2004

Submitted by
Partnership for Community Health, Inc.

PCH Contact Information:
Mitchell Cohen, Ph.D.
245 West 29
th
Street
Suite 1202
New York, NY 10001
Phone: 212 564 9790
E-Mail Mitchell@pchealth.org

TABLE OF CONTENTS

ACKNOWLEDGEMENTS.............................................................................................................................ii
THE FACE OF AIDS...................................................................................................................................... iv
African American MSM............................................................................................................................. iv
Recently Incarcerated...............................................................................................................................viii
IDU.............................................................................................................................................................. x
Non-IDU....................................................................................................................................................xii
Homeless ..................................................................................................................................................xiii
Anglo MSM............................................................................................................................................... xv
Women Aged 13 to 49 ............................................................................................................................xvii
Youth (13 to 24 Years of Age).................................................................................................................. xx
Chronically Mentally Ill ..........................................................................................................................xxii
EXECUTIVE SUMMARY.......................................................................................................................... xxv
Positive Outcomes with Some Cautions ................................................................................................. xxv
Changing Profile of the HIV/AIDS Epidemic ....................................................................................... xxvi
More Service with Fewer Resources .............................................................................................. xxvi
Unmet Need .................................................................................................................................... xxvi
Profile of PLWH/A......................................................................................................................... xxvi
Service Needs................................................................................................................................xxviii
Service Gaps .................................................................................................................................... xxx
Barriers to Receiving Services ........................................................................................................ xxxi
Vision of the Commission....................................................................................................................xxxiii
Goals.....................................................................................................................................................xxxiii
Goals for 2005-2008 ..................................................................................................................... xxxiv
Last Word.............................................................................................................................................. xxxv
INTRODUCTION....................................................................................................................................xxxvii
How the Plan is Organized.................................................................................................................xxxviii
Methodology ........................................................................................................................................ xxxix
HIV/AIDS Care Assessment Project: Questionnaire and Focus Groups (H-CAP) ...................... xxxix
Sampling ............................................................................................................................................. xl
Recruitment ........................................................................................................................................xli
Consumer Survey............................................................................................................................ xliii
Analysis...........................................................................................................................................xlvii
Compensation....................................................................................................................................... xlviii
Data Sources......................................................................................................................................... xlviii
1. WHERE ARE WE NOW..............................................................................................................................1-1
MISSION OF THE COMMISSION............................................................................................................1-1
VISION AND VALUES OF THE COMMISSION....................................................................................1-1
Regional Planning.............................................................................................................................1-2
CONTINUUM OF CARE.............................................................................................................................1-3
Interface with Comprehensive Prevention Program................................................................................1-6
PRIORITY AND ALLOCATIONS.............................................................................................................1-8
Priorities ...................................................................................................................................................1-8
FUNDING THE CONTINUUM OF CARE..............................................................................................1-13
An Overview of Funding........................................................................................................................1-13
Ryan White Title I, II and MAI CARE Act Funds ................................................................................1-14
Minority AIDS Initiative (MAI) .....................................................................................................1-14
Non-Commission Allocated Ryan White CARE Act Titles II, III, and Part F Funding........................1-16
Service Allocations ................................................................................................................................1-17
Medi-Cal and Medicare..........................................................................................................................1-19
Veterans Administration ........................................................................................................................1-19
Housing and Urban Development (HUD)..............................................................................................1-19
Los Angeles County Department of Social Services .............................................................................1-20
Food Stamps...........................................................................................................................................1-20
Substance Abuse and Mental Health Services Administration (SAMHSA)..........................................1-20
Child Health Insurance Program............................................................................................................1-21
Department of Children and Family Services (DCFS) ..........................................................................1-21
California Childrens Medical Services .................................................................................................1-21
WIC and Child and Adult Care Food Program......................................................................................1-21
Los Angeles Department of Transportation (LADOT), Metropolitan Transit Authority (MTA), and
Access Services, Inc. (ASI)....................................................................................................................1-21
Recommended 2004 RW TI and TII Allocation....................................................................................1-23
OUTCOMES................................................................................................................................................1-25
Mortality: Death Rates and Case-Fatality Rates ....................................................................................1-25
Progression from HIV to AIDS ......................................................................................................1-27
New AIDS Cases by Ethnic Populations ........................................................................................1-27
New AIDS Cases by Risk Group....................................................................................................1-28
New AIDS cases by SPA................................................................................................................1-29
Medication and Adherence.....................................................................................................................1-30
Taking Medication ..........................................................................................................................1-30
Adherence .......................................................................................................................................1-31
Opportunistic Infections (OIs) ...............................................................................................................1-33
Quality of Life........................................................................................................................................1-35
PROFILE OF THE LOS ANGELES EMA AND THE EPIDEMIOLOGY OF PLWH/A..................1-38
Persons Living With AIDS ....................................................................................................................1-39
The Risk Group Profile of PLWA..........................................................................................................1-39
The Gender Profile of PLWA ................................................................................................................1-40
The Ethnic Profile of PLWA..................................................................................................................1-41
Subpopulations with Small Numbers of PLWA....................................................................................1-42
PLWH/A: Disproportionate Impact .......................................................................................................1-43
Ethnic Racial Distribution of HIV and AIDS .................................................................................1-43
Regional Variation .................................................................................................................................1-44
CO-MORBIDITIES ....................................................................................................................................1-50
Substance Use ........................................................................................................................................1-50
IDU and non-IDU ...........................................................................................................................1-50
IDUs (Not MSM/IDUs) ..................................................................................................................1-50
MSM/IDUs......................................................................................................................................1-51
Poverty ...................................................................................................................................................1-51
Insurance ................................................................................................................................................1-52
STDs.......................................................................................................................................................1-53
Syphilis............................................................................................................................................1-53
Gonorrhea........................................................................................................................................1-54
Hepatitis ..........................................................................................................................................1-55
Tuberculosis ....................................................................................................................................1-56
Homelessness ..................................................................................................................................1-56
NEEDS, UNMET NEEDS, GAPS, AND SERVICES DELIVERY BARRIERS ..................................1-60
Service Categorization ...........................................................................................................................1-60
Most Needed Services............................................................................................................................1-60
Top Rated Needs ....................................................................................................................................1-61
Top Service Needs: Gender Differences ................................................................................................1-64
Top Service Needs: Ethnic/Racial Differences ......................................................................................1-65
Top Service Needs: Risk Group Differences .........................................................................................1-68
Top Service Needs: SPAs ......................................................................................................................1-71
Top Needs by Stage of Infection............................................................................................................1-73
Awareness, Demand, Utilization, and Satisfaction with Care Services.................................................1-74
Service Gaps...........................................................................................................................................1-79
BARRIERS ..................................................................................................................................................1-83
Structural ................................................................................................................................................1-87
SPECIAL POPULATIONS........................................................................................................................1-93
Men of Color Who Have Sex With Men (MSMC) ................................................................................1-94
Recently Incarcerated.............................................................................................................................1-96
Undocumented PLWH/A.......................................................................................................................1-99
Men who have Sex with Men (MSM)..................................................................................................1-102
Latinos/as or Hispanics ........................................................................................................................1-105
Severely Mentally Ill (SMI) .................................................................................................................1-108
Women of Childbearing Age (WCB)...................................................................................................1-111
Homeless ..............................................................................................................................................1-115
Youth....................................................................................................................................................1-118
2. WHERE ARE WE GOING?........................................................................................................................2-1
GOAL AND OBJECTIVES .........................................................................................................................2-1
Overall Goals............................................................................................................................................2-1
Progress Since 2002 .................................................................................................................................2-1
Service Achievements.......................................................................................................................2-3
Planning Accomplishments...............................................................................................................2-4
Infrastructure Development Accomplishments ................................................................................2-5
Objectives through 2008 ..........................................................................................................................2-6
Service Delivery Goals .....................................................................................................................2-7
Planning Goals and Objectives .........................................................................................................2-9
Infrastructure Goals.........................................................................................................................2-10
3. HOW WILL WE MONITOR OUR PROGRESS AND RESULTS.........................................................3-1
SERVICE DELIVERY GOALS AND OBJECTIVES ..............................................................................3-1
PLANNING GOALS AND OBJECTIVES.................................................................................................3-5
INFRASTRUCTURE GOALS AND OBJECTIVES.................................................................................3-8
4. ATTACHMENTS..........................................................................................................................................4-1

TABLES
Table 1-1 Sample Quotas by Ethnicity and Gender........................................................................................................xli
Table 1-2 Open Recruitment Sessions..........................................................................................................................xliv
Table 1-3 Final Sample.................................................................................................................................................xlvi
Table 1-4 Sample Quotas by Ethnicity and Gender vs. Unweighted and Weighted N=732.......................................xlvii
Table 1-5 Focus Groups............................................................................................................................................. xlviii
Table 1-1 Data Elements of Service Category Summary Sheets...................................................................................1-9
Table 1-2 Decision Making Paradigms..........................................................................................................................1-9
Table 1-3 Decision Making Values .............................................................................................................................1-10
Table 1-4 Funding Scenarios .......................................................................................................................................1-10
Table 1-5 Service Category Prioritization ...................................................................................................................1-10
Table 1-6 Continuum of Care Services by Ranking and Priority ................................................................................1-11
Table 1-7 Year 16 Allocation Timeline.......................................................................................................................1-12
Table 1-8 All 2004 Care Service Funds.......................................................................................................................1-13
Table 1-9 Trends in HIV/AIDS Funding.....................................................................................................................1-18
Table 1-10 2004-5 Allocations ....................................................................................................................................1-23
Table 1-11 PCP by Ethnicity (per 100,000).................................................................................................................1-34
Table 1-12 PCP by Race among PLWA (per 100 year) ............................................................................................1-35
Table 1-13 ESTIMATE OF PLWH/A.........................................................................................................................1-38
Table 1-14 Population and PLWA by SPA.................................................................................................................1-44
Table 1-15 Insurance by Ethnicity and SPA................................................................................................................1-53
Table 1-16 Needs Assessment Survey Services (2004)...............................................................................................1-61
Table 1-17 Top Ranked Service Needs by Gender......................................................................................................1-64
Table 1-18 Service Need Rankings by Ethnicity.........................................................................................................1-66
Table 1-19 Comparison of Risk Group Ranking of HIV/AIDS Service Needs ..........................................................1-69
Table 1-20 Service Need by Stage of Infection...........................................................................................................1-73
Table 1-21 Types of Barriers .......................................................................................................................................1-84
Table 1-22 Special Population Estimates
1
...................................................................................................................1-93
Table 1-23 MSMC: Top Barriers to Care....................................................................................................................1-96
Table 1-24 Recently Incarcerated: Top Barriers to Care .............................................................................................1-99
Table 1-25 Undocumented: Top Barriers to Care......................................................................................................1-102
Table 1-26 MSM: Top Barriers to Care.....................................................................................................................1-105
Table 1-27 Latinos: Top Barriers to Care..................................................................................................................1-108
Table 1-28 Severely Mentally Ill: Top Barriers to Care............................................................................................1-111
Table 1-29 Women of Childbearing Years (18-49): Demographic Profile ...............................................................1-111
Table 1-30 Length of HIV Infection in WCBA.........................................................................................................1-112
Table 1-31 WBCA: Top Reasons for Skipping Medications ....................................................................................1-113
Table 1-32 WCBA: Reasons for Not Seeking Care...................................................................................................1-114
Table 1-33 Homeless: Top Barriers to Care ..............................................................................................................1-118
Table 1-34 Youths: Reasons for Not Seeking Care...................................................................................................1-121
Table 2-1 2002 Goals and Accomplishments ................................................................................................................2-1

FIGURES
Figure 1-1 Recruitment Process.....................................................................................................................................xlii
Figure 1-1 SPA Map......................................................................................................................................................1-2
Figure 1-2 Continuum of Care Model ...........................................................................................................................1-5
Figure 1-3 Comprehensive Prevention Program............................................................................................................1-7
Figure 1-4 Priority and Allocation Process....................................................................................................................1-8
Figure 1-5 Distribution of $547 Million in Care Funding ...........................................................................................1-14
Figure 1-6 Distribution of $36.6 million 2004 RWT I, II, MAI Funds .......................................................................1-15
Figure 1-7 Breakdown of Title I & II 2004 Funding...................................................................................................1-16
Figure 1-8 Resource Expenditures for 2004 ($41.8 million).......................................................................................1-24
Figure 1-9 HIV/AIDS Deaths by Ethnicity per 100,000 of L.A. EMA Population ....................................................1-26
Figure 1-10 Case-Fatality Rates...................................................................................................................................1-27
Figure 1-11 AIDS Cases by Year of Diagnosis by Race.............................................................................................1-28
Figure 1-12 AIDS Cases by Year of Diagnosis by Risk Group ..................................................................................1-29
Figure 1-13 AIDS Cases by Year of Diagnosis by SPA..............................................................................................1-30
Figure 1-14 Medication by Stage of Infection.............................................................................................................1-31
Figure 1-15 PLWH/A Adherence to Medication.........................................................................................................1-32
Figure 1-16 Reasons for Skipping Medications by Ethnicity......................................................................................1-33
Figure 1-17 Reasons for Skipping Medications by Mode of Transmission ................................................................1-33
Figure 1-18 Quality of Life Physical Health.............................................................................................................1-37
Figure 1-19 Quality of Life Emotional Health .........................................................................................................1-37
Figure 1-20 Living with AIDS by Risk Group ............................................................................................................1-40
Figure 1-21 PLWA by Gender.....................................................................................................................................1-41
Figure 1-22 Living with AIDS by Ethnicity................................................................................................................1-42
Figure 1-23 Impact of HIV/AIDS Epidemic on Racial/Ethnic Communities in LAC................................................1-43
Figure 1-24 Population and PLWH/A by SPA............................................................................................................1-45
Figure 1-25 AIDS by Zip.............................................................................................................................................1-46
Figure 1-26 Regional Variation - PLWH/A.................................................................................................................1-49
Figure 1-27 PLWH/A Living Below Poverty Level....................................................................................................1-52
Figure 1-28 Syphilis Cases (1998 -2003) ....................................................................................................................1-54
Figure 1-29 Gonorrhea Cases (1998 - 2003) ...............................................................................................................1-54
Figure 1-30 Trends in Tuberculosis by Ethnicity ........................................................................................................1-56
Figure 1-31 Homelessness & Transitional Housing by Race, Gender and Risk Group..............................................1-58
Figure 1-32 Ranked Service Needs..............................................................................................................................1-63
Figure 1-33 Need - Difference by Gender ...................................................................................................................1-65
Figure 1-34 Comparison of African American Service Need to ALL PLWH/A........................................................1-67
Figure 1-35 Comparison between Latino Service Need and All PLWH/A.................................................................1-67
Figure 1-36 Comparisons between API/Other Service Needs and All PLWH/A .......................................................1-67
Figure 1-37 Comparison between MSM/IDUs Service Needs and All PLWH/A.......................................................1-70
Figure 1-38 Comparison between IDUs Service Needs and All PLWH/A.................................................................1-70
Figure 1-39 Comparison between Heterosexual's Service Needs and All PLWH/A..................................................1-70
Figure 1-40 Top Service Needs by SPA......................................................................................................................1-72
Figure 1-41 Comparison of Need between PLWH and PLWA...................................................................................1-74
Figure 1-42 Consumer Awareness, Demand, Utilization, and Satisfaction of Most Needed Services .......................1-76
Figure 1-43 Consumer Awareness, Demand, Utilization, and Satisfaction of Moderately Needed Services.............1-77
Figure 1-44 Consumer Awareness, Demand, Utilization, and Satisfaction of Less Needed Services ........................1-78
Figure 1-45 Need Ask Service Gaps.........................................................................................................................1-80
Figure 1-46 Ask-Receive Service Gaps.......................................................................................................................1-82
Figure 1-47 Barriers to Services ..................................................................................................................................1-86
Figure 1-48 Top Service Needs for MSMC.................................................................................................................1-95
Figure 1-49 Top Service Needs Among Recently Incarcerated ..................................................................................1-99
Figure 1-50 Top Service Needs for Undocumented PLWH/A..................................................................................1-101
Figure 1-51 Top Service Needs for MSM living with HIV/AIDS ............................................................................1-104
Figure 1-52 Top Service Needs among Latinos ........................................................................................................1-107
Figure 1-53 Top Service Needs among Severely Mentally Ill ..................................................................................1-110
Figure 1-54 Top Service Needs for WCBA...............................................................................................................1-114
Figure 1-55 Injectable Substance Use in Last Six Months ........................................................................................1-116
Figure 1-56 Top Service Needs for Homeless PLWH/A...........................................................................................1-117
Figure 1-57 Top Service Needs for Youths living with HIV/AIDS..........................................................................1-120

ATTACHMENTS
Attachment 1 2004 Needs Assessment Survey..............................................................................................................4-1
Attachment 2 Focus Group Outline for Selected Populations .......................................................................................4-1
Attachment 3 Focus Group Outline for Out-of-Care.....................................................................................................4-1
Attachment 4 Secondary Information Sources ..............................................................................................................4-1
Attachment 5 SPA Descriptions ....................................................................................................................................4-1
Attachment 6 Service Provider Network Plan...............................................................................................................4-1
Attachment 7 Service Category Summary Sheet - Example .........................................................................................4-1
Attachment 8 Formula for Estimating PLWH/A...........................................................................................................4-1
Attachment 9 Poverty Levels.........................................................................................................................................4-1
Attachment 10 2004 Survey Cross Tabs........................................................................................................................4-1
Attachment 11 2004 Survey Cross Tabs Selected Populations ..................................................................................4-1
Attachment 12 HIV/AIDS Interface Technology System (HITS) Project Description.................................................4-1
Attachment 13 Community Advisory Boards and Consumer Involvement ..................................................................4-1
Attachment 14 2002 Recommendations from the Assessment of the Administrative Mechanism...............................4-1
Attachment 15 Core Service Program Indicators ..........................................................................................................4-1
Attachment 16 Goals and Objectives for Implementing Core HIV/AIDS Services......................................................4-1
Abbreviations
ADAP AIDS Drug Assistance Program
Af Am African American
API Asian / Pacific Islander
ASD Adult/Adolescent Spectrum of Disease
ASO AIDS Service Organization
CHHS Commission on HIV Health Services
CPG Community Planning Group
EMA Eligible Metropolitan Area
HARS HIV/AIDS Reporting System
HAV Hepatitis A
H-CAP HIV/AIDS Care Assessment Project
HCV Hepatitis C
HET Heterosexual
HITS HIV Interface Technology System
IDU Injecting drug user
IMACS Information Management of AIDS Clients and Services
LAC Los Angeles County
MSM Men-who-have-sex-with-men
MSMC Men-who-have-sex-with-men of color
Native Am Native American
OAPP Office of AIDS Programs and Policy
OI Opportunistic infection
PCH Partnership for Community Health
PLWH/A Person living w/ HIV/AIDS
PP&E / P&P Planning, Priorities, and Evaluation renamed to Priorities and Planning Committee
PPC Prevention Planning Committee
RWCA Ryan White Care Act
SCSS Service Category Summary Sheet
SHAS Supplemental HIV/AIDS Study
SPA Service Planning Area
STD Sexually transmitted diseases
TB Tuberculosis
TG Transgender
VA Veterans Assistance
WCBA Women of Childbearing Age
Youth PLWH/A 24 years of age or younger

ii
ACKNOWLEDGEMENTS

This Comprehensive Care Plan has benefited from the collaboration of many persons and
organizations. First, and foremost, it reflects over 1000 people living with HIV/AIDS
(PLWH/A) who completed surveys, focus groups, and key informant interviews in 2002 and
2004. We further acknowledges those who have participated in various other studies and
tracking tools used for secondary analysis, such as SHAS, ASD, Young Mens Survey, and the
African American Mens Study.

In 2004 the data was collected under the umbrella of the HIV/AIDS Care Assessment Project (H-
CAP). Los Angeles County HIV/AIDS care providers played a key role in the recruitment of
participants for H-CAP, and in addition to their day-to-day responsibilities, 34 recruiters at
different agencies successfully recruited clients. We acknowledge the substantial effort that
went into this effort. Special thanks is extended to those agencies that nearly reached or
exceeded their recruitment goals including: AIDS Project Los Angeles, Northeast Valley Health
Corporation, Valley Community Clinic, Prototypes, Tarzana Treatment Center, Being Alive
Long Beach, Bienestar, Common Ground, Project Angel Food, El Proyecto del Barrio, City of
Long Beach Department of Health & Human Services , Childrens Hospital of Los Angeles,
HALSA, Los Angeles County Olive View Medical Center, Caring for Children and Families
with AIDS, JWCH Institute, Inc., Project New Hope, Los Angeles SHANTI Foundation, The
Catalyst Foundation for AIDS Awareness, and Cri-Help, Inc.

The Commission on HIV Health Services (Commission)s Priorities and Planning (P&P)
Committee oversaw the needs assessment and comprehensive care planning project: Brad Land,
Kathy Watt (Co-chairs), Hugo Farias, Mark Parra, Anna Long PhD, Elizabeth Marte, and Kevin
Van Vreede donated considerable time and energy toward this work. They have participated in
the process, guided the effort, and been invested in the outcome.

Los Angeles Countys Commission on HIV Health Services (Commission) staff, led by Craig
Vincent-Jones, has provided critical input and supervision. H-CAP would have been impossible
to implement without his support and commitment to have the voice of PLWH/A systematically
represented in the planning process. Commission staff, Libby Boyce, Sherry Rolls, Jane
Nachazel, Nicole Werner, and Virginia Gomez provided logistic support during the many facets
of the process.

Doug Fry, MD MPH of the Department of Health Services, HIV Epidemiology Division, was the
conduit for much of the epidemiological information used in this Plan. Several persons at OAPP
provided support. Michael Green, PhD, provided helpful feedback on the methodology. Ms.
Diana Vasquez, RN, MPH, has assisted in assuring that providers participate in the process, and
her support and that of the other contract managers helped make H-CAPs first year a success.
Juhua Wu was instrumental in assisting with the beginning phases of H-CAP including the IRB
Application and provider training.

The H-CAP staff and interviewers spent numerous hours contacting recruited PLWH/A,
scheduling interviews and conducting them. Their conscientious efforts and patience in
iii
conducting interviews helped assure the high quality of the data. Ms. Irene Hung provided
oversight of the field procedures and interviewers were Matt Rowe, Felipe Hoyos, Vanessa
Unkeless, Lavern Maison, Jeannie Kim, Sara Lee, Jose Luis Toledo, and Sam Morris listened
and recorded the service needs, gaps, and barriers of PLWH/A in the Los Angeles EMA.

The main analysts and synthesizers of information in the Plan, Mitchell Cohen, PhD, Lucia
Orellana, Irene Hung, Felipe Hoyos, and Lavern Maison from the PCH, deserve special mention
for their efforts in synthesizing the H-CAP information so that a representative voice of
PLWH/A can express their needs, barriers and gaps in services can be part of the HIV/AIDS care
planning process.
iv
THE FACE OF AIDS

The first step in planning HIV/AIDS care services is to understand the health care and social
challenges faced by a wide diversity of populations infected with HIV and AIDS. Below, nine
composites are compiled based on epidemiological, survey, and focus group data. They place a
face on AIDS and a referent for health care planning. These are the communities whose life can
be improved when their needs are met. Listen to how they talk about their lives, and ask yourself
what HIV/AIDS services can address the many challenges they face as PLWH/A.

African American MSM

I live in Los Angeles proper in the central part of LA. Im in my mid-thirties, and I like having
sex with other men. Maybe Im gay, but I dont like that label its for White boys and doesnt
describe me. I hear that most Black men living with HIV and AIDS are around my age, but I
know infected Black brothers who are teenagers and I know brothers who are grand-dads. Ive
been to school and completed college (a lot of us have). Ive never been married, but some of
my buddies that I have had sex with are married and have kids. They are on the down-low if
you know what I mean.

I first took the test in 1992. I had a good reason to take it at the time, but wasnt ready to go back
for my results two weeks later. I waited and was tested again about a year later. This time I got
my results, but I didnt really try to get any medical services for about three years I felt fine,
and I hadnt heard anything but bad news about the medication they were putting people on. In
school I read about that Tuskegee experiment where Blacks were infected with STDs and I am
really suspicious of clinics run by White folk. When I finally did go for help, it was only
because I had pneumonia.

Since then Im feeling better than I have in a long time. I know a lot of this is because of the
medication. Ive been on antiretrovirals and protease inhibitors. Ive never liked them but I
know they help. At first it was really difficult. The clinic was really busy and the doctor didnt
really have the time to explain everything to me. That was okay, because Im a college graduate.
I can read right? But things were really complicated, so I didnt really get all the detail, and at
first I had all the different meds and times mixed up. But after a while you get the hang of it, and
you know what to take, how and when. But even then, sometimes it gets to be too much, trying
to eat regularly, dealing with rashes, numb legs, and the worst is the diarrhea. Besides
sometimes Ive got other things on my mind and just forget to take my meds, and at least a few
times, Ive just gotten tired of the whole routine and taken a little holiday from my meds.

For some of my infected brothers, HIV isnt the only problem we have. A lot of my friends have
had other STDs and quite a few people I know are hooked on drugs. Some of my unlucky
friends have spent time on the street or in a shelter. About ten years ago I had a friend that was
put out by his family and ended up on the street. People may be a little more accepting now, but
believe me, not that much has changed.

v
Before, when I saw a person sleeping on the street I thought, how can a person sink so low? But
later, when I was sick and between jobs I came pretty close to being on the street myself. But I
was lucky; friends and relatives let me crash in their apartments. Still, even for me with a
college education, being homeless is just a matter of a little bad luck.

While I dont qualify for food banks some friends say they can help. But they say its difficult to
get there during work, and its impossible to get good fresh food. Theres only so many times
anyone can eat canned soup and boxed macaroni and cheese, and thats when were lucky
enough to meet the income level for the food bank. You might not think about it but sometimes,
but something as basic as food is hard to afford, and we need nutritious food that is familiar to us
and good for us.

Ive never been in jail and never been arrested, but maybe half the guys I hang with have. They
tell me you dont want to go to jail, especially if you have HIV. They say others in jail avoid
you or worse, and it can be impossible to get the right meds. Its tough to get linked to services
and programs when you get out.

One of the hard things for me is finding and staying employed. Its never been easy, but since
Ive been sick off and on its harder to find and keep a job that pays all the bills. Health benefits
dont come with part-time work. Im lucky I guess, Im working now, but I wont make more
than $20,000 this year.

That doesnt seem too bad when you just hear it, but heres the deal:

I take home maybe $1,500 a month from my part-time work and sometimes the side-effects of
the meds make me miss work so its less. My rent is $850 a month, not including my utilities, or
stuff for my oral hygiene, or household cleaning products --you have to live in a clean place.
Some of my friends have Section 8 housing, and while it is less rent, many Section 8 apartments
are in unsafe neighborhoods. Besides, Section 8 is all but impossible to get these days even for
people who dont work. So, my rent is way over half of what I make, and with food and medical
costs there is nothing left. I need my car to get to work and to my medical appointments. Even
then, sometimes Im too sick to drive around to all my appointments. The car is a big expense,
but its not safe to take the bus at night in certain areas and if you have to go across town it can
take hours with all the transfers and I cant spend all that time and still keep a job.

Let me tell you about what folks like me need to stay alive. First, we need medical services.
Thanks to the CARE Act we get that. The basics follow, housing (not a shelter or SRO), but a
place to live that is safe and our own and then food. We need information about affordable
housing, programs, and support services to help us get housing and keep it, and food and
nutritional support so we can stay healthy.

And man, the system works against people like me who try and work. I cant afford health
insurance, but Medi-Cal keeps telling me I make too much money to qualify. I really need help
with paying for the medication. The same goes for housing and food programs. Even the food
vi
banks say I make too much. So, maybe Im thinking Ill have to quit my job just to get the
benefits I need to stay alive.

If someone were to ask me if there were enough services out there, Id have to say yes there are.
Is it easy to get those services? Are they easy to use? Not always, not even generally. My case
manager tired to help, but sometimes I think she is guarding the gate to services I need rather
than helping me get them.

When I first entered the system I didnt know what services were available to me, and, like I
said, eligibility rules are a maze. Finding out the range of services is hit and miss, its more word
of mouth than some comprehensive source you can go to and say hook me up. If youre lucky,
solid directories and word of mouth will point you to where to go. But sometimes I find that the
best services are across town or the Valley and the folks dont look or act like you and thats
another problem. Even when I have found a service I really need in a directory, it doesnt tell
you how to get in, what to say, what you have the right to ask for, or question.

Sometimes, once youve made it through the door, the treatment is impersonal; you feel like a
number or a fly on the wall someone suddenly noticed after a half an hour. Will that keep me
from getting services? No, not me. But it might make someone that was just diagnosed think
theyll come back later, or a young kid head for the door.

Right now Im doing ok. Ive learned enough about the system to get what I need. But like I
said, it would be much easier for me to just quit my job and accept the hand-outs. When you
dont have anything thats when you get the most help. But then the disease would take my
sense or worth and esteem, and then what would be left?

Undocumented PLWH/A

Ive been in LA for seven years now. Right now Im living in Pico Union with some other guys
from my country, friends I made after I got here. They dont know my HIV status, and they
cant. Id lose my bed and my space when we get jobs.

I got tested when I was really sick with the flu about two years ago. Id been going to the
botnica to get the remedies we use at home, but nothing helped. Finally I went to a clnica in
my neighborhood one that will see us for free or low cost, wont ask about papers and really
just wanted to help. They had some people in that day doing a special outreach and HIV and
STD testing. I got talking to some of the outreach workers and it sounded like it was really
something I should do. So I got tested and made another appointment to get my results. When I
went back the doctor told me what I didnt want to know and gave me a form to take to an AIDS
clinic.

When I left I burned the form so that no one would see it. My flu symptoms went away. So I
prayed Id stay healthy and didnt talk about it. I had to be sure nobody would see me near an
AIDS clinic. Its a really small world where I live. At that point I just got a place to live. I
spent the good part of two years since I arrived on the street, doing any day work I could find. I
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couldnt jeopardize what Id worked for. What if Immigration found out? What if my family
back home found out?

Im not like some of my friends who whore around a lot and do heavy drugs. I drink a little and
do some weed on weekends. When I work, I am able to send some money home to my mother
and sister. I have a girlfriend in my hometown and I try to stay faithful, but sometimes, when I
drink too much, I get lonely and things happen. I hoped to bring her up here and we could get
married and start a new life with some possibilities, but now Im positive, and I dont know what
to say to her. When I look back at it, it was the drinking that probably got me in trouble. You do
stupid things when youve had too much to drink, and even though I knew about HIV I thought
about my friends who take really big risks and they arent HIV positive. I didnt think it would
happen to me. Its not fair.

After that first bout of the flu, my health got better and stayed pretty good for about two years.
But about three months ago the virus really got hold of me. My color was bad, I was tired all the
time, and I lost a lot of weight. I could tell everyone was talking about me. I knew I had to go
see a doctor, but I dont have health insurance who can afford it? So I went back to the clnica
for that piece of paper, and they referred me to a place a place in East LA.

I was surprised when I went to the AIDS clinic. They speak Spanish so I understand what they
tell me, and the services are good. This place understands people in my situation; they only ask
the questions they have to. They gave me a good case manager that has good contacts for other
services that I need.

The clinic said the virus has really taken over my body my viral load whatever that means
had skyrocketed and I had to start taking these pills. They are very expensive but the clinic says
they can help me get them for free. But even if I could get the pills where would I keep them
and how would I take them? Because I live with a lot of other guys, I couldnt take them the
way the doctor told me I needed to (some with food, some three times a day). If I started taking
all these pills every day for a long time my friends would know. So I took the pills they gave
me, then I stopped. I still have the prescription slips for more, and I need to put them someplace
safe because people may see them and know that I have an illness. I could lose everything.
Anyway, Im feeling better now both physically and spiritually, so I dont think I really need the
medication anymore. Its better to wait until I really need them again to take them. I figure Ive
come through worst than this and Im a fighter. I have to be.

At the clinic my case manager invited me to a private group of other HIV positive persons
working in LA without legal papers to discuss our HIV care needs. We were all pretty thankful
that the clinic gave us good care. If we were sick back home we couldnt get this kind of care.
Besides the medical care we mostly need really basic things like food and housing, and someone
to tell us where to go to get them. If I had a place to live, even just a room by myself, then I
could take the medicine in a private place and I wouldnt have to worry about others finding it.

Like me, others in the group said they got referrals from their case manager to other services, but
I dont know if they are safe to use. Sometimes when I went to other services people didnt
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speak my language or understand my situation. The only way to find out about good services is
by talking to others you know understand your situation. But even sitting in a waiting room
youre not going to ask somebody where you can find safe AIDS services. You dont really
know who they are.

It used to be that facing my condition was my biggest problem. Now that I accept that I am HIV
positive, I have different issues. The AIDS clinic provides good medical care, but I cant find
many services that will help you without papers. Even with my case manager, I dont know
what is available to me, and Im afraid that if I ask theyll take away what I have. For housing
and food everyone wants you to fill out papers; its the first thing they ask for when you come in
the door. Ive seen people go in speaking English and they still ask first about papers. I see
people getting into apartments, and getting on special programs for medication, but no one really
offers that information. I dont know if its for people in my situation, or if you have to be a
citizen. I am really thankful that I get medical care, and, you know rather than jeopardize that, I
am better off not asking too many questions.

Recently Incarcerated

Im White, 40 and have AIDS. I was caught again tryin to support my habit -- armed robbery.
This time around I was sentenced to 5 years. This isnt my first time in the joint. I did a lot of
time with the CYA, and then little time in other states. Sometimes it seems like Ive been inside
most of my life, and being White, Im used to being in the minority.

Like a lot of us in the joint, I have both Hs: Hep C and HIV. Rumor has it if you stay inside for
long youll end up with TB too. Before a few pills would get rid of TB, but now they have this
resistant type. .If AIDS doesnt kill me, then I guess the Hepatitis or TB will unless I get both a
cure and a liver.

I got diagnosed with HIV maybe 12 years ago, and probably got it in jail. Maybe it was sharing
a needle for drugs or a tattoo. Maybe it was sex; I was passed around a lot when I was younger.
And, you know, they dont even have condoms in the jail!

Anyway, when I was arrested this time HIV was in my record. Still, it didnt make any
difference to the sheriff. When I was arrested I was put in a cell in the city jail for days with no
meds and no doctor. Then after I pled guilty and was sentenced to Lancaster it was like being in
a leprosy colony. Maybe 50 of us were positive, and they put us all together. There were
teenage gang members and older guys in their 60s. There were first timers for doing some
drugs right along with rapists and killers real nasty freaks. Still, we were all put in the same
area and couldnt do regular activities. We didnt get to do nothing except sit around.

Even when they finally hooked me up with a doctor and he gave me meds the rest of the guards
and staff really didnt understand or care about my disease. Sometimes we got our meds and
sometimes we didnt. Sometimes the staff wouldnt be there and youd go without a dose, or
two or three. It didnt matter if we were supposed to take it with food it was take it now or
not at all. Once I got someone elses medication. I looked at it and was going to take it until I
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realized there were too many pills and some of them didnt look like mine. I feel sorry for
whoever got mine that day.

It wasnt until I got really sick with AIDS and they moved me to the Medical Facility in
Vacaville, North of San Francisco. The medical care was better there and I recovered enough to
get out of bed after a few months. The worst part was it was so far away. Only a few friends or
family could come up from LA to visit and then only one or two times when they thought I was
dying.

I thought I had it bad, but this HIV positive con on my ward from another state said that when he
got sent to prison in California all his medical records were in another prison system in his home
state. He was mad as hell because when they tested him he had to start all his paperwork again.
They didnt even try to get his medical record! He couldnt even get a case manager before his
test result came back.

I just got out the joint, so what I told you before is water under the bridge. Ive seen people beat
themselves up with regret, and done a fair bit of that myself, but Ive got to look forward, not
back, not now. As soon as I was out I headed for LA, and now Im tryin to get re-re-
established. Having AIDS puts things in perspective, and now I want to re-connect with my
family and kids.

If you think bein in the joint with AIDS is hard, let me tell you bein free and living with AIDS
on the outside is no piece of cake. I dont think my story is much different from most guys that
have been in jail and have AIDS, but it might help you understand who we are, what we deal
with, and what we need.

When I got out I was on parole and was sent to a post-incarceration program in LA. They gave
me 2 weeks of pills to tie me over. The program tried to hook me up with a clinic and doctor and
housing, but I spent a few weeks on the street and in a couple in shelters. I dont know how
people do that, shelters I mean. Id rather sleep on a bench. Finally the program came through
with an SRO. Im waiting for something better, an apartment or somewhere where I dont have
to bundle everything up every 28 days and move over to another room. At least Im on a list.
Im one of the few White guys down here, and Im one of the luckier ones I guess.

At first there was too much going on to keep my medical appointments. I had to see my parole
officer, and I looked up a couple of old friends. They were infected too, and they were really
into crystal meth. But that stuff was way too crazy for me. Sometimes, I smoke a little weed (it
does help me feel better, makes it easier to eat, clears my head). But Im careful, I try not to
take too many chances, I cant risk going back inside.

Anyway, one of the hardest things about being out is not having everything in one place, having
to schedule doctor appointments and parole meetings and having to get here and do that. Its
hard having all those choices and responsibilities without a phone and a car.

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Bottom line, I finished my 2 week supply of meds and then I was off them for a couple of
months. At first I was feeling pretty good even some of the side effects of the meds like
diarrhea and numbness went away. And I was lucky, and found a place to stay and a job (a
major accomplishment) which paid some bills even if it didnt have insurance. Things were
really looking up when I started to feel bad. Pretty soon I was too sick to go to work and, well,
that was the end of that job. Down here its hard to stay out of trouble. You get down in the
dumps and you buy a bottle.

After a few months I had to go to the ER with pneumonia. They admitted me and I was lucky. I
got better and a case manager there hooked me up with an agency. The agency got me back on
my meds and got me GR, which was actually easier to get that than SSI. Now Im waiting for
SSI to kick in. I still hope for better housing and still need a job and food. But everywhere I go
you have to fill in papers and unless I lie about my time in jail, Im not eligible for a lot of the
services.

Sometimes when I look back at things where I am, what I have to run around and do, how
much things have changed in just five years sometimes it seems like it would be been easier to
just be back inside.

If you ask me, what incarcerated people need (those just getting out and those on parole) is a
comprehensive program. One that understands all the adjustments we have to make when we
step outside those walls. One agency with a whole array of services we need would help, not
just go here for this and see this person for that. Hey, even the streets have changed, the
busses are different, I dont remember how to get from one end of town to the other.

We need services that deal with medical care, food, housing, transportation, drug treatment, and
mental health. For the last five years the biggest thing I had to do was to go from my cell to the
doctor, to the yard and to the mess hall. Now people expect me to get half way across town and
back just to get medication that will make me feel even worse, take a bunch of tests, and fill out
forms to get on waiting lists! Once youve been in jail youre labeled so its even harder to get
any services. Hey, sometimes its just too much. For me it was, and when I didnt get my meds,
I got sick and almost died. But thats water under the bridge.

IDU

Most of the IDUs I run into with this problem are men. The women, I guess, they dont share as
much, are around, but not as many as men. A lot of IDUs are gay, or have both men and women,
but there are some of us that are just IDUs. Were heterosexual, like back east, where the
epidemic is as much about IDUs as it is about gays. Our group is pretty mixed, mostly White
and Black guys when you go downtown; on the east side there are a lot of Latino IDUs and in
San Fernando where I live, too.

I dont have insurance; actually I dont have much of anything. Right now Im in a treatment
program (again) so I have someplace to live. Otherwise Id be on the street unless I could hook
up with some of my friends. Like most of the guys I know Ive got the double whammy HIV
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and Hepatitis C. I know that I really have to leave the drugs and booze alone with my liver half
shot the way it is.

I dont know when I got HIV or Hep C. I know I got really sick a year or so ago and was living
on the street and ended up in the hospital. Thats when I got the news. I spent about two weeks
in the hospital and then I got set up with some services, and was on a waiting list for drug
treatment, but could only get methadone outpatient. So after that I just messed around. I figured
they got the wrong blood or something. I was fooling myself I wasnt ready to deal with where
I was in my life.

Since then Ive been taking it a day at a time. Like my addiction, I'm learning how to deal with
the HIV on a daily basis. Dealing with this information is like learning how to walk again. So
many things have to change. Its knowing that I've got to use a rubber, knowing that I've got to
abstain from sex and know that I've still got a drug addiction, and any little thing might push me
over. It's a lot to deal with.

Im doing some job training, trying to eat right, but taking my meds is really difficult. In the
program Im in, everything is pretty set. Its hard to eat when youre suppose to, its hard to go to
group and hear folks talking about the problems theyre having trying to kick and cope with
your health. Every other day or so Ill ask whats the point of trying to get and stay clean; I
figure Ill die from the hepatitis or the HIV in a few years anyway.

I think we need different services that are more sensitive services for us. Sometimes I feel it
would be easier to get services if I were gay; here in L.A most of the services seem to be for
them. There are fewer programs that really understand what we need. Sometimes not being gay
can be a stumbling block. I went to one service and as they got to know me better and found out
I was a junkie and had junkie behavior and that stuff, that just made things worse.

First, weve got to have the basics food and shelter. We need to be able to spend our time
doing something more productive than scrounging for a bed and figuring out where we can get
some food. Then, we need medical services with doctors that understand addiction; that
understand how hard it is to get clean and why we sometimes have a problem with all the
medication they want us to take. We need transportation to get to all our appointments and
medical and dental care.

We need really comprehensive services that can help us get back on our feet and be there when
we feel like were going to just give up or go crazy. One thing we really need is people that have
been there out there, who are there to help with mental health services. The folks you meet in
the centers and programs dont have a clue. They know the addiction side, but many of them
dont know what rock bottom really means and how desperate you get when you know youve
got the HIV ticking away with the Hep C right behind it.

Is it hard to use services? Sort of, once you find them, once they get past your addiction, once
youre clean and ready to use them. The hardest thing about using services is really getting past
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the denial, and then getting past the less than feeling (like you really do deserve the illnesses
you got and you dont deserve a second chance.)

I want to go back to work. I know it will be hard, but I remember how it used to be; you know
how you get that good feeling about working and the extra money. But Im worried, too. Ive
heard that if you make too much they start messing with your money, and your services. Seems
like theres always a catch someplace.

Non-IDU

People dont like to think about it but you can get HIV from using drugs, not shooting, not
needles, just drugs. You say you have HIV and people think youre gay or an IDU. But drugs
will make you do things you would never do and makes you take chances you dont even think
about. People say we (us non-IDU drug users) make up less than 3 percent of all people with
HIV and AIDS. I think its more like ten percent. The drugs, we use it all, crystal meth and
speed, but we dont shoot it. I know some folks that still smoke heroin too. Weed is common
and used regularly. In some crowds GHB, poppers and ecstasy are used pretty regularly (or at
least at party time.)

Im pretty typical I think. Im living with some friends in Hollywood. I left home before I
finished high school and even though I keep saying Im going to finish my GED, I havent gotten
around to it yet. I get by doing odd jobs, when they present themselves, and the four of us that
live here manage to pull together enough to get what we need and pay the rent.

You know I think I know exactly when I got infected. I knew that I was in a bad place, at a bad
time and I got high anyway. I just didnt care. I just figured okay, just a little fun, a little
harmless fun and nobody gets hurt. Right...

I think when I found out I was infected it was like just another day, I didnt think much about it
at the time. I said yeah, what else is new. And that was that. I just refused to think about it.
Couldnt, what was I going to do about it anyway? I started to feel like it was just part of some
big plan, leave home, get off the streets, manage to dodge bullets and the other dangers of the
streets just to put myself it a stupid position and jump right into the fire. I didnt care, what was I
going to do anyway? But then I got sick, really sick and for some reasons I figured I was too
young to die.

About six months after I was tested, I got into services. By default of course, it wasnt like I
made the effort on my own. I got really depressed. My friends got worried. I wouldnt eat or
get out of bed (part of it was I felt like crap, the other was that I couldnt move, I didnt see the
point.) So I spent about a day and a half in the ER. They didnt have a bed and my friends
wouldnt take me back home. Then I got admitted for a couple of days and talked to a social
worker that hooked me into services. The most important thing was the case management. I got
fixed up with appointments and got my meds (which I really hate to take). I know its stupid, but
I just have problems with it. We dont have the right food and the right time. I cant make it to
the food pantry and back on the bus. I get worn out trying to get to my doctors appointments.
xiii
Sometimes I know the services are there, but the door seems so far away, and the wait seems so
long, that I just get half way there and turn around. I figure someone else will take my place and
maybe they really need it more anyway.

Sometimes I still use. One thing hard about having to have HIV and be a drug user is that there
are so few programs for people like me. Im not an IDU, I dont need methadone and I dont
understand programs that say stay clean one day at a time. I never used everyday. I dont use
once a week. Those programs arent for me. There need to be programs that deal with the guilt
you have after youve done something stupid that has changed your life forever, what drives me
back to the drugs is that guilt and anger, not a physical addiction. My worst fear is that Ill end
up using, and risk taking and someone else will end up like me. Point me to a program to help
me with that and Ill show up every day. Ill even take my meds, and finish my GED. I may
even write home

Homeless

As if things arent bad enough all my stuff got picked up by the city and dumped this morning, or
at least everything I couldnt carry or pull. Why dont I take my meds? The few things I had are
in the bottom of a trash truck right now. Even if I could hold on to some of the medication,
where would I keep it safe, dry? Forget about refrigeration. Right now Im concerned about my
other poncho and tarp, my dry shoes and my other big bag on wheels. Im concerned about the
$8.50 that I had in cans and bottles. Im trying to figure out where Im going to sleep tonight. If
I have to sleep on the street, on the ground -- I wont. Ill sit at a bus stop or lean in a doorway.
When you are homeless and you cant find a place, you dont sleep. Once I slept on the
sidewalk. It looked okay at the time, but I woke up with ants all over me. Never again, it wasn't
cool. Every one that slept on that sidewalk always woke up with ants covered all over them. In
some places you get the red ones.

But even then no doubt better here than back home, no snow, no freeze and you can stay cool
most days in the summer, but its different here, especially since they keep herding us around.
Get comfortable move over there. Get settled, pick up and dont come back up here. Problem is,
the services (what little there are) are here. When I get those sores on my hands from the cans
that I cant shake, theres a place were I can get food and a shower. I can even get nurse to take
a look at me when its bad. That time I had the flu so bad it turned into pneumonia, by buddies
dragged me to the clinic and they got me in the hospital. That time, if I was where the police are
telling me I to go today, well, I would have died on the street. The clinic, the kitchen, the
services are all miles away.

What came first, the HIV or the homelessness? I cant really say. Ive always knocked around a
lot. Cant stay in one place too long. Back when I was younger, say 25, I actually had a job and
a car and I had a year of college under my belt. That was when you could have a decent job with
a high school diploma.

But something happened. I think I just fell off a ledge someplace and things go dark and
confusing and I lost one job, found another, lost it and kept spiraling into a deep hole. The whole
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time I was living fast and furious. I know what they say about how you get HIV. A lot of stuff
happens when youre on the street and get to drinking and smoking rock and you dont care.

I got tested once when I was in the clinic. The nurse said I should because I told her Id shot
drugs and had sex without condoms. (Condoms are like money with the right folks.) So I got
tested and was told I could get housing and food and medication. And, I got a lot of papers, and
a chair in a waiting room and a list of rules. I felt fine at the time (I had a place to crash and a
little money in my pocket) so I didnt need to wait around all day so someone could look at me
the way people do. So I left. I didnt go back for three years.

So now, I had an appointment with a case manager, or at least I think it was, but I stashed the
card in one of my books and Im still trying to figure out if thats in my backpack or in the city
trash truck. I know if things get really, really bad, I can pick up something at the 99 cent store,
act a little wild and get a shower, medication and three meals a day. Only problem, I wouldnt
be able to leave when I wanted to. I figure thats my best bet right now for comprehensive
services.

A couple of years ago I was getting a check, but I lost track and really dont have what it takes to
go back through all that paper work again. You need help and encouragement to do that, and my
best friend lost it and is doing time. Thinking back, us and a couple of other guys had a place to
live. We started with a loose SRO and bunked when we could get in and finally got a room and
a hot plate and had some pretty good times all things considered. We even got a used little
icebox and kept some soda and stuff in it. I could have used it for my meds if I had meds then. I
took antiretrovirals for a while, but the stuff was too difficult, and I couldnt eat right so I
stopped. They didnt go to waste because those are like the condoms; like money on the street.

People ask about my health. Well I figure Im doing pretty good right now. I tested positive for
TB but got on some county program and actually got put up in a room as long as it took to take
all my meds. But then I finished my meds and well, something else like transitional housing sort
of didnt fall into place. Ive had Hep A (laid me up for a while), no surprise considering where I
get my food sometimes. I dont have that much sex where am I going to do for a date? So I
dont and havent had VD since I was a kid. But I drink, especially on a day like to day, where
Im all shuffled up and half my stuff is God knows where. Yeah, this is a day for a drink or two
or three.

I know who the president is, and I know what date it is. I dont see or hear things like some of
the folks down here do. But Ive had my share of really low times, and sometimes its hard to
ignore the looks, and stares and inhumane treatment people throw at us, when you know that
they may be only a few hard knocks away from the pallet next to you. Ive tried counseling (its
not for me.) Ive already told you what I need right now; my stuff and a place to keep it and me
safe and dry, some food and some decent treatment. I need a place to relieve myself thats not
dirtier than the curb or a corner rat alley. I need what everyone else needs, shelter, food first,
then a way to get around; I cant get to services in the valley by bus and back before dark and if
I did, whos going to watch my stuff. Then I guess I need my teeth pulled or at least some of
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them; try to floss when you dont even have clean water to drink without loosening a hydrant.
Medical care is important, but not as important as the basics.

Anglo MSM

We remain the largest group of people living with HIV and AIDS, there are estimated to be more
than 115,000 of us. More than one in four persons living with HIV and AIDS is an Anglo MSM.
I live in West Hollywood; about half of Anglo MSM live in the heart of the city (the Metro
Service Planning Area). Many of my friends live in the Long Beach area and some in the San
Fernando and San Gabriel Valleys. Although Anglo MSM with HIV/AIDS range in age from
the mid twenties to the mid fifties, almost 10 percent of Anglo MSM are older than 55. We tend
to be more highly educated than other groups with HIV/AIDS. More than sixty percent of us
have spent some time in college and close to one in five have attended graduate school.

Although most of us are single, close to one in three lives with a partner. Even though we tend to
have higher education only about one in five are employed full or part time. Our incomes are not
what they should be; about 85 percent of us are trying to make do with an income of less
$27,000. It depends on who you ask, some people say that more than 90 percent are living
within 300 percent of the federal poverty level (about $56,500). Thats a lot of variation, and I
think thats the point. There are Anglo MSM living in poverty, and others that see private
doctors and have plenty of money. But for most of us, we are okay today and are never quite
sure what tomorrow will bring. We can pay most of our bills (excluding medical), as long as we
are working, and we are working as long as we have jobs and are well enough to keep them.
There are other groups that are worst off, every day. But many of us have spent some time living
under those circumstances also.

About one in five Anglo MSM have been in jail. Ive never been incarcerated but Ive met men
that have been and have had friends that have been arrested.

Im one of the lucky ones with decent health insurance, but then Ive got a job. About half of
Anglo men with HIV and AIDS are uninsured. Of those with some type of coverage its
generally through Medi-Cal or Medicare; less that 12 percent have private insurance.

Ive been infected for about ten years now and thats pretty typical. More than sixty percent of
Anglo MSM have been infected for over eight years. About three of every five of us have some
sort of disabling symptoms, with two-thirds of us having an AIDS diagnosis.

Despite the length of time most of us have been infected, many of us are doing okay physically.
Im in better health than when I first finally dragged myself to the doctor. (I went once to get my
test results and a second time to get my T-cell count. I was doing okay and not interested in
getting on any drugs at that time, so I just dropped out of the system for a while. It wasnt until I
started getting sick that I finally had to accept that it was time to get into treatment. I needed to
wait as long as I could. It seemed that so many of the people I knew, started on treatment and
then the periods when they were doing well got shorter in duration and they seemed to be doing
poorly a larger percentage of the time. I felt that once I started treatment, or even paying too
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much attention to the test results that my health would start to deteriorate. I held out as long as I
could. If I had known then that I would feel this good, I would have started seeing my doctor
sooner.

More than three-fourths of us have been on some type of medication (antiretroviral or protease
inhibitor) at some point. Ive heard we are more likely to be on medication as a group when
compared to the overall group of people living with HIV and AIDS. Once were on, we tend to
be reasonably compliant, with approximately 30 percent never skipping medication (more than
any other group). Among those of us that arent that perfect, about 45 percent of us simply have
forgotten a dose here and there (Ive done than myself more times than I like to admit). Still
about 25 percent just dont want to take the medications and stop at some point, and another 20
percent just cant tolerate the side effects. Among my friends, two out of three of us have taken
a little time off from the medication at one point.

We tend to have different rates of some co-infections than other groups. TB is pretty rare, with
only about 12 percent even having a positive skin test. I dont know anyone that has had active
TB. A higher percentage of us tend to have had gonorrhea (over 45 percent) and that is higher
than among other ethnic groups. About four in ten report a history of syphilis and one in four of
us have had hepatitis B. Maybe because we seem to get medical care, although we have a
history of these infections, recent STD diagnoses are low. Less than four percent of Anglo MSM
have been diagnosed with gonorrhea in the past two years.

Although less than ten percent of Anglo MSM feel that injection drug use led to their HIV
infection, about 40 percent of us have used a needle at some point. Crystal meth is by far the
drug most frequently injected, followed by crack and heroin. Most of us drink alcohol (almost
70 percent), and of those about ten percent report drinking at least once per week.

You might find it hard to believe, I did when I first started to realize it, but one in five Anglo
MSM have been homeless at some point. Transitional housing, the type that is provided through
AIDS services, has been used by almost one in four MSM. I was close to using it once, but had a
friend that I was able to stay with until my situation improved (an informal type of transitional
housing that I think we use more often than we admit.) Among the people I know, at least one in
ten has a precarious housing situation and could be without a place to live in the next three
months.

Our service needs are pretty much what you would expect; medical and dental services are
needed by over 90 percent. Case management is very important with 75 percent identifying this
as a critical need. Support services like food and housing are also needed by a substantial
proportion (approximately 70 percent).

Actually, Im able to get most of the services I need due to my insurance. I have friends who are
uninsured, but they have been linked up to a variety of health and support services. They tell me
that once you have a good case manager its much easier to get the services you need.

xvii
Ive heard that the initial experience is pretty overwhelming. I have a friend who told me that it
took him a week to go through the directory of services to try to figure out what was available,
and what was close to him and then to try to match that information with what he really needed.
He said, I knew every food bank that was offered to me out there. I knew of every different
place I could go to get medical help and what was offered where. I knew how to go about
getting prescriptions. I knew how to go about doing the things I needed to get done. Now it was
up to me to go knock on the doors and find out what help I wanted to take advantage and what
help I didn't want to take advantage of.

Not knowing about a service seems to be the number one barrier. Unlike my friend, three out of
every four Anglo MSM dont know certain services are available. Another frequently reported
barrier is the long wait to get an appointment. Although the services are available, we frequently
discuss problems that we see with the services. In addition to having to wait a long time to get
appointments, especially for some specialty services, Ive talked to several people that share my
concerns about the experience and expertise of the provider. I sometimes wonder if the quality
couldnt be better, if the wait for an appointment really needs to be as long, or if more of the staff
could be up on the latest information. If someone were to ask me Id say that access to services
is pretty good, but the services need to be enhanced to make them more up to date and easier to
use. One of the biggest problems we face is the excessive paperwork. I wish there were a way
not to have to keep filling out the same papers, and having to take the same information with you
every time you go to a new provider. But on the other hand, there are still very real concerns
about confidentiality so for now, Id be happy if they could find a way to streamline the
paperwork.

Women Aged 13 to 49

Sometimes I think women are the forgotten victims of HIV and AIDS. Most people think about
men, at least in the United States. But there are plenty of women living with AIDS and HIV
(often living in spite of it) that people dont really think about enough. We live for our children
and our families and for ourselves, in hope that others wont have to go through what we do.
Were about 12 percent of all people living with HIV and AIDS, but we tend to get lost in the
bigger picture.

About 10 percent of us are 24 years or younger. When I think about young women, sometimes
under the age of 21, trying to navigate the service system it makes me shudder.

Most of us are women of color, African Americans or Latinas, and most of us live in the central
and southern areas of Los Angeles County. Two out of every three women with HIV and AIDS
have children, like me. I meet women in support groups and a few of them dont know how they
were infected. I know; I have my ex to thank for it, curse him for it, but I know I have to get past
the anger, and I have for the most part. I dont have time to waste on anger now. Like me, most
women were infected through sex with a man. Less than 15 percent of us got HIV from injecting
drugs.

xviii
Women are frequently in a bad situation in society anyway and this is very clear among women
with HIV and AIDS. Almost half of us have not finished high school and fewer than one in three
are employed. Most of the women in my support group are like me, living below the poverty
level (you try living on less than $720 per month). Many of us, about one in five, feel that we
could become homeless in the near future. A lot of us, even though we have a place to live,
dont feel its a safe place to live. Sometimes I look around and think what a terrible place to
have to raise my kids. But then I remember having to sleep a couple of nights in the car (when
we had a car) and then I realized, this isnt great, but it could be a lot worse.

Ive mentioned my kids but havent really told you much about them. My youngest is seven,
shes doing really great and because I knew my status and I took medication when I was
pregnant so shes negative. Then there was my oldest girl; she would have been eleven years old
now. Didnt find out I was infected until I got her test back, she was almost three at the time.
My ex, well we were still together at the time, never told me he had HIV. Im not sure he even
knew.

My little girl didnt grow as well as she should have. She always seems to be sick. If a kid
around the corner had a cold, she caught it. She was so sickly. I tried all the home remedies that
my aunties, cousins and the ladies at church recommended, but she didnt do any better. The
doctors just kept telling me to feed her better, more often, that babies get colds and ear
infections.

Then they started to ask me about HIV. I thought they were crazy. I was fine, my husband was
fine and we were good church going people. So I said, go ahead, do whatever tests you want,
just find out whats wrong with my baby. Well, Im sure Im not the only woman with this story.
Ive heard it from other women throughout the years. People have to start talking to each other,
protecting themselves and the people they say they love. This should never have to happen to
anybody, and especially not a baby.

So I figure Ive been infected for at least 12 years. Thats longer than most women I meet. Most
have been infected for between 6 and 12 years, and about a third, less than six years. Its so sad
to know this is still going on, now when the word is out there and women know about HIV. But
hey, somehow we always trust our men. Maybe we need to learn to trust ourselves and take care
of ourselves. Ive learned that you have to look out for yourself and your family and sometimes
thats not comfortable and not easy.

Its hard on a family when a kid is sick. I cant tell you what its like to lose a child. For a while
I stopped taking my medication, I stopped taking care of myself completely, and then my
youngest came in when I was feeling really bad. Even at her young age she knew what was
going on. She said, Mommy, are you going to leave me too? Cant you stay with me? Sis is
okay; Grandma is in heaven with her. I need you to stay here with me. And shes what has
brought me through. I do all I can to stay as healthy as possible because I am going to be there
for her. I will be there to see her graduate from high school and college, she needs me and Im
not going anyplace, not yet.

xix
So now, I take my medicine (even though it really has some ugly side effects). I felt like a big
bloated frog. I started to look at myself in a different way. Nothing fit me anymore; I got bigger
in all the wrong places. Id ask myself, "What is going on with this medication? Finally Id had
enough and I told myself, I m going to the doctor and hes going to fix this". Then the doctor
tells me that I have to keep taking the medicine. So I do, and the side effects dont improve and I
feel about as ugly and sick as I ever had. Then right when Im ready to throw all of it out the
window, theres my girl saying, Mom, you look pretty today. Mom, you took your medicine
didnt you? I swear she can read my mind. So yes, I do think about not taking it, but I never
miss a dose. I think, what if I hadnt taken it when I was pregnant with this angel? No, I take it
no matter what.

Even though we dont have much money, weve got pretty good healthcare. I have Medi-Cal
and that helps a lot. Some women (about one in five) dont have any health coverage and
although this is less than the overall groups of people with HIV and AIDS, its still too many.
Then there are the women with good jobs and they are able to get private health insurance, but
thats not most of us, only about two in every ten. (Those in my group pray they can stay healthy
enough to keep working.) My daughter had really good care. They had special pediatric
programs set up for children with HIV. And there were even activities for siblings, they really
helped my youngest understand what was going on.

Of all the services I need, I really need dental care. My teeth are terrible; sometimes Im
embarrassed to smile. We dont have a car so we spend a lot of time on the bus. On those days
when I have a lot of appointments, taxi vouchers are really important. Besides transportation, we
need basic things; food, housing. Its sad to say, but when youre unable to work and have a
child to support, you cant live on $800 a month. I use the food pantry and vouchers to
supplement what I put on the table. It helps so that I can spend the little we have on other things
we need.

Going to my group really helps. Having other women that know what Im going through is
really important. It also helps to be able to talk to women who were where I was a few years
ago. After all, someone was there for me. Being there for others helps keep me going during
those hard times. My daughter has also made some good friends, other kids with moms that are
living with the same thing.

Its the group that really turned me on to a good case manager years ago. I was able to get a
female. That was important for me because I feel that she understands my needs more than a
man could. Finding services was a big problem for me. Once I was diagnosed they referred me
to medical care and other services. My baby was sick so I took care of her. I was in denial so I
didnt go to my appointment and really sort of ignored the whole issue. Finding the services
once I started tying to address my own issues wasnt easy, the case manager and group really
helped with that.

Another problem for me and I guess other women is using the services. Sometimes I dont feel
the services are sensitive to women. Most of these services are set up for men since there are
more men infected than women. When a woman, especially someone like me, (church going,
xx
not really exposed to a lot) goes in and sees the posters on the wall that really are aimed at gay
men, I get embarrassed. It makes me uncomfortable. I understand they are just trying to be
sensitive to the majority of people that they serve, but they should try a little harder to be
sensitive to the rest of us too.

Another problem is all the paperwork, and thats not just a problem for women. I hear
everybody complaining about that. There is so much red tape, so many complicated forms; Im
never sure what stage of applying, getting, being denied, reapplying that Im in. Its so
confusing and tiring. Once we can get our benefits, things really improve. But they make it so
hard to get them. Im lucky, I was born here, I can speak the language and read. I was the one
that use to do our tax return. Some of the women at the agency where I go for support dont
speak English and even though there are interpreters and people to help them with the
paperwork, it has to be overwhelming. I mean, if its hard for me; I know it has to be worse for
these women.

Youth (13 to 24 Years of Age)

We are a small but growing group and represent about 12 percent of people living with HIV and
AIDS. We are called youth. But I think its not really fair for us to all be grouped in together.
Someone forgot to notice that a 13 year old has almost nothing in common with a 24 year old,
except in the case of HIV. We are very different (even though it might not seem like it to
someone 50). But I dont know how we all keep getting lumped together like this; maybe its
easier for somebodys paperwork or computer program. Anyway Ill humor you. Ill talk
about us like we are a nice neat group.

Some of us are just kids that got HIV through no fault of our own (their parents or doctor or
somebody else screwed up). Others are more like adults because we engaged in the behavior
that got us where we are today. There were some, if not most of us who really didnt know any
better, even in these times, we just didnt know and if we did we sure didnt believe we knew
anyone with HIV. After all we were strong and invincible and the people we hung with were
like us. They looked healthy and safe. We just didnt think and didnt really know.

About two-thirds of us live on the south, South Bay, Long Beach and Metro areas of Los
Angeles County. Only about one in ten live in the San Fernando Valley. Unlike older folks with
HIV almost half of youth with HIV are female (this is really scary when you think about it.)

So most of my friends (at least people my age that I see in my youth groups) are people of color.
We really dont match the general population in terms of ethnicity. Most youth with HIV are
Latino (about 45%) or African American (40 percent); only about three percent are Asian.

More than half of us are gay. This is pretty similar to overall group of people living with HIV
and AIDS. Most of us are young and single although about 18 percent have partners.

Like most youth we dont have good steady jobs or equity in a nice house. In fact, for the
most part its pretty pathetic. Almost one in three of us have no income at all (and its not
xxi
because were too young to work.) No funds coming in means we are just living the best way we
can.

But what do you expect when all most one in five havent finished high school (not that that
diploma really gets you enough to live on). But for every youth I know that didnt graduate, I
know another that did. And out of every five that did graduate, three actually did do some
college level work.

Like many Im putting in my time at the local community college. Ive got a friend that is on his
way to grad school. For me, if things work out, Ill transfer to a four-year college soon. I think
many of us know that you need to get an education or else youre doomed. But some of us are so
messed up or are just trying to deal with the next day, the next week, that a future really isnt a
real thing for us.

The income structure for youth seems to be one of extremes. Along with the 25 percent of us
with no income, two-thirds make $25,000 or less. Still theres the group that make as much as
$34,000. When youre young and dont have kids (some of the young women do), $34,000 is
okay even in LA. Most if not all of us are eligible for HIV CARE services (translation we
make less than three times the poverty level).

I know some younger folks that have been in jail, mostly for drugs but sometimes for theft and
other crimes. Its tough for kids especially those under 18. A lot of times the young ones (13,
14, 15,) end up in the situation where they have to care for themselves but legally cant make
decisions or sign papers without getting emancipated. I know because Im not from LA. I came
here when I was 13 from Nevada. I spent some time on the streets, got infected, did some drugs
and then got cleaned up, got emancipated and pulled my life together a little better than it had
been. (Didnt I make that sound easy? Its not; it was hell and it still is. But I can see a little
further down the road now.)

When you dont have parents in the state (not that you would call them up if they did) and
theres no one to take care of you or to speak up for you, you end up in Juvie for any little thing
you do. Sometimes I dont think its because they think its where you belong, sometimes I
think they just dont know what else to do with us. I mean, foster parents dont want teenagers
and generally teens dont want their own parents or anyone else trying to act the part. So you
end up in Juvie and then if you dont straighten up you get a record that sticks (get charged and
convicted as an adult). About one in five youth I know spent some time in the CYA (Cal
Youth Authority) or adult correction system.

Given our lack of income, education and just about everything else, its no surprise that four out
of ten of us have no health insurance. When we do have coverage its generally through Medical
(about 44 percent) and Medicare (38 percent). If you do get a job or live with your parents (fat
chance) you might have private insurance.

Most youth havent had HIV very long. About one in five of us have had HIV for about a
year. Another two in five have had HIV between one and three years. Occasionally you meet
xxii
some of the older youth that have had HIV or AIDS more than 8 years (but thats really
unusual). Most of us are in pretty good health about three-quarters dont have any symptoms
yet. Thats really good, but it makes denial more lingering. You can play games with yourself,
tests can be wrong, false-positives and all that. Then if youre in denial, you might not be
responsible (being safe for the next person).

Because so many of us havent been infected that long, the majority dont use any medication.
Only about 45 percent of us are on medication and about half are tolerating it pretty well and not
having side effects. Only about a third say that they have some side effects that bother them a
little. Less than one in five that are on medication say they really have bad side effect.

Even though you may hear that a lot of kids use drugs, Ive yet to know any anyone with HIV
that thinks they got it because they were using needles. I know that about one in ten youth
inject something, but I think they have access to clean needles even though the system makes it
really difficult for you. About ten percent do some crack and another ten percent do cocaine.
Among all youth, about one in five have used cocaine, crystal meth, speed or uppers; and about
ten percent use poppers and ecstasy and marijuana. The things that we dont talk about is the
impact of drugs on HIV (bad for your body, screws with your immune system) and bad on your
mind. I mean were still having sex. And I still havent figured out how to make safer sex
automatic, so if Im loaded and horny, chances are sex isnt going to be safe. So I dont do
drugs. not when Im going to party; I know what can happen.

So about services We need what everyone else needs, but we need it to be sensitive to us.
Were 24 at best and sometimes as young as 13. You cant treat us all like adults; its not fair.
Its like we come in for services, and get this big run around. It hasnt happened to me in a while
but I remember what it was like, Hey do you have a parent guardian someone that can sign
this permission form for you. Oh, well uh, let me get my supervisor And dont even try to
go into an emergency room or apply for housing or funding. You cant even get in some shelters
unless you lie about your age. If youre messed up and really ready to get clean, try to find help
without getting involved in some type of government system. Actually if you are a homeless,
sick strung out kid, under the age of 18, the fastest way to get help is to shoplift enough stuff so
that they just dont rough you up and throw you out. Stash enough in your pockets so they call
the police and so that the police take you in. What do we need? Somebody to realize that some
of us are on our own and that we are people too. We need guidance, but respectful guidance and
care. More like mentoring instead of taking care of us.

Chronically Mentally Ill

I was 45 last year; I spent my birthday in a psych ward under observation because I just couldnt
go on. I have a lot of trouble getting on with my life, the days seem to melt into one another and
I just cant cope sometimes. For a while Im fine, I go to work and clean my apartment just like
everyone else. But then there are times when the whole world turns against me and I cant fight
the tide. It was during one of those times when I think I got HIV, one of those dark times when I
didnt care if I lived or died.

xxiii
Ive seen the inside of a lot of psych units and offices, the longest for six months. I always seem
to get myself together after a while. Im back living with my mother now; she takes me in
sometimes when Ive lost a job, when I cant take care of everything on my own. My mother
takes care of my daughter when she visits in the summer. Shes 12 now and her visits are less
frequent. Her dad took her when she was three. Given the HIV its better this way. I dont want
her to see me when Im sick or when Im not thinking straight. I dont have a check to help my
mom with the bills right now. Because I was working for a while last year I dont have my
Medical or disability, but Im working on it now.

Even with the HIV Ive been pretty healthy. Ive had HIV for about ten years; during a
particularly deep spiral. I left home for a couple of months, lost track of time and who I was. I
wound up in a psych unit eight months later, pregnant and with HIV. Im still not too sure where
I was for all that time. The important thing is that I found my way back. I found out because
they tested me when I got pregnant the second time. I think I stay healthy because my mom
really takes care of me. She forces me to eat, even when I dont want to. She makes sure I eat
the right food and take my medicine when Im supposed to. She nags me about my
appointments and makes sure I get enough rest. I always thought I was supposed to take care of
my mother but now shes taking care of me. It makes me feel helpless and sad and dark. I take
my medication most of the time because my mom reminds me. I know when shes not around I
forget. When I was living on my own it got to be too much for me. Id get confused and end up
with a bunch of medicine left at the end of the week.

I seem to keep a yeast infection. Otherwise Im pretty healthy, somehow I escaped hepatitis and
most of the other STDs. (Okay, I think I did. I might have gotten tested and treated during one
of those times when I was in that deep dark hole I cant see out of.) I smoke too much and drink
sometimes, but mom doesnt keep alcohol in the house (not since dad died) and I cant smoke in
the house.

In terms of services, I dont need much other than medical, dental case management and mental
health services, transportation sometimes. When I was on my own I needed everything
housing, food, the basics. Right now group therapy is working well. Especially since the group
is folks that all have HIV. Groups with folks without HIV dont really help much, they arent
coming from the same space and they dont have the same nightmares. It would be good to get
more individual 1-on-1 help, but its hard to come by. Im open to more mental health services,
but a lot of times the problem is that the psychiatrists dont seem to want to help you; they just
want to prescribe you drugs. Every time you go in and say the anti-depressants aren't working
they say, Dont give up on it, let's increase the dosage. Then I get into a fog and before I
know it Im back inside again.

What makes it hard to get services? Going through all the paperwork all the time, over and over.
Finding people that will take the time to listen to me, treat me like an individual instead of a
number. When Im having problems I barely know my name or address, it gets lost in the dark
with all the other information that I need like my social security number or why I walked in the
door in the first place. Sometimes I think maybe its not safe to give the person asking the
questions all that personal information but they wont tell me why they need it or what theyre
xxiv
going to do with it. Then its really hard to complete the paperwork and I tell them I have to go
and Ill finish some other time. I think my state of mind is my biggest problem getting and using
services. Luckily when Im not having problems I do pretty well and the people at the clinic get
to know me.

xxv
EXECUTIVE SUMMARY

Positive Outcomes with Some Cautions

Los Angeles County receives high marks for its continuum of HIV/AIDS care. Medical
care is available to those who seek it, and overall mortality and morbidity of PLWH/A
continue to decline. Large disparities in mortality between ethnic communities have been
significantly reduced but not eliminated. One reason for continued disparities is that
communities of color enter the care system later in the disease progression. Improved
access to early intervention services, and the referral links between HCT and care should
improve this outcome further. Regarding morbidity, PCP rates continue to decline, with
the most dramatic decrease among African Americans. However, African Americans are
still significantly more likely to be diagnosed with PCP than other ethnic communities.

The number of new AIDS cases continues to drop, but the pattern is not consistent and
ranges from a slight increase in 2002 to nearly a 20% decline in new AIDS cases in 2003.
Clearly some variation is due to reporting lag, but given the effectiveness of the
medication, there is room for improvement in keeping HIV from progressing to AIDS.

Additional epidemiological research might be done to better understand the factors
leading to the progression to AIDS. One area for improvement is increasing the number
of PLWH on medication. Where nearly 90% of PLWA are on antiretrovirals, 60% of the
PLWH who are symptomatic report taking antiretrovirals. Another areas is adherence,
where 50% of PLWH/A say they have skipped talking their medication. Those most
likely to skip are African Americans, and there is a strong relationship between drug use
and poor adherence. When asked why they forget to take their medication, the majority
of PLWH/A say they forget, suggesting the need for adopting a better method of
reminders. Other reasons are didnt what to take them and side effects. These
suggest a need for demonstrating the positive impact of medication and better side effect
management -- in short, more personal attention to these issues at the clinics and by case
managers.

Confirming the drop in morbidity, the majority of PLWH/A say their current physical and
emotional health are good to excellent. As expected PLWA are much more likely to
report fair or poor physical and emotional health, but still only about 15% of PLWA say
their physical or emotional health is poor.

Regardless of stage of infection, the majority of PLWH/A say that their physical and
emotional health is better now than when they found out they were infected. Of all stages
of infection the symptomatic PLWH appear to be having a worse time, particularly with
their emotional health. This, and other data, suggests a need for mental health counseling
among those symptomatic HIV persons who are at risk of progressing to AIDS.
xxvi

Changing Profile of the HIV/AIDS Epidemic

More Service with Fewer Resources

The number of PLWH/A continues to increase, and they enter the Continuum of
HIV/AIDS Care poor, or become poor, as they spend down their resources. The number
of PLWA in Los Angeles County has grown from 14,811 in 1997, to 19,752 in June
2004. As more individuals become infected with HIV and fewer infected progress to
AIDS, the number of PLWH will increase. As of June 2004 there are an estimated
57,654 PLWH/A, up over 5,000 cases from 2002.

At the same time the Ryan White CARE Act funds have decreased from $42 million in
2003 to about $36.6 million in 2004. According to the client tracking system, of those
who know their status, nearly 22,500 or about 52% of PLWH/A receive some CARE Act
funded service, of which about 15,700 (36%) receive medical outpatient care provided by
CARE Act funded providers.

As estimated, 53% - 60% of PLWH/A would be eligible for outpatient care paid for non
CARE Act sources like Medi-Cal, Medicare, or the Veteran Administration.
Consequently, the number being served is about the expected proportion. According to
the Financial Needs Assessment there may be room for additional Medi-Cal or Medicaid
coverage, and, at the same time, according to the unmet need estimate, there are those
eligible who are not being served.

Unmet Need

Based on a methodology accepted statewide, there are an estimated 15,185, or about 35%
of PLWH/A who are aware of their status and have not received medical care for a year
or more. The protocols linking HCT to Care will help bring those who test positive but
dont seek care into care. A challenge for the care system will continue to be improved
tracking those in the care system who drop out and encourage them to continue in care.

Profile of PLWH/A

The biggest shift in the profile of PLWA in the last 7 years is that Hispanics have
overtaken Anglos and now present a plurality of PLWA. The risk group and gender
proportions have remained roughly the same.

However, although exact figures cannot be calculated because HIV reporting that started
in 2002 is not yet considered generalizable, the disproportionate impact of HIV in the
African American and Latino communities is clear. While nearly 10% more Anglos are
living with AIDS than HIV, nearly 4% more Latinos and African Americans are living
with HIV than AIDS.

xxvii
In 2002 the Comprehensive Plan noted, Los Angeles County is witness to many
different HIV epidemics divided by age, race, and lifestyle. The Plan identified a
number of epidemics that can be identified and they are updated below in this Plan:
1. A mature epidemic represented by Anglos and MSM, and those IDUs who were
infected early in the epidemic and have survived.
2. Those more recently infected represented disproportionately among communities of
color. Latinos represent the largest numbers, but African Americans with just under
10% of the population represent nearly 22% of the PLWA and over a quarter of
PLWH.
3. A growing epidemic among young gay men, particularly young gay men of color and
party drug users who engage in high risk behavior for both disease progression and
transmitting HIV to others.
4. A hidden epidemic among the undocumented, which are most likely to be
undercounted due to significant barriers to care including lack of knowledge, fear of
being reported, and discrimination within their own community.
5. The transgender population which has a much higher infection rate than other
populations and are more likely to be diagnosed with AIDS.
6. The American Indian population, who make up a very small segment of the overall
population, but are disproportionately impacted by HIV.

Greater efficiency and effectiveness of care services can be achieved by targeting
services among these different populations. That is, developing models of service
delivery for the different population segments noted above. For example if outpatient
care and case management were based on a system wide acuity service model, then those
who are stable and have less demand for services would be allocated fewer units of care,
while those with multiple co-morbidities and health care needs would be allocated a
wider range of CARE Act funded services.

For wrap around services, the care system has made progress in targeting high-need low
demand services such as child care to those most in need. On a service by service basis
the Commission and OAPP should continue to develop protocols for services such as
dental care and transportation that target those most in need. To target these populations
successfully across all SPAs require the SPNs understand their populations and work
together to identify underserved populations.

Knowledge can lead to more realistic expectation for services among PLWH/A. It is a
challenge for the Commission and OAPP to explain their rationale for service allocations
and the Continuum of Care to PLWH/A. For example, the needs assessment
demonstrates that PLWH/A continue to have very high expectation for food and housing
services, but within the context of all services, CARE Act funds cannot be expected to
fulfill many of these basic needs. While the Commission is doing an excellent job in
involving different populations into the planning process, conveying their rationale to
both providers and PLWH/A remain a priority.

xxviii
Service Needs

Based on data collected from 732 PLWH/A who participated in the HIV/AIDS Care
Assessment Project (H-CAP) survey and focus groups, Figure 1 below shows the top
needs as well as the awareness, demand, utilization, and satisfaction for each of the top
services. The highlights of the graph indicate:
The most needed service in 2004 is outpatient medical care, the same as in 2002. In
2004 about 95% of PLWH/A said they needed outpatient medical care in the past
year.
The second and third most needed service in 2004 is dental care and psychosocial
case management, both 77%. Dental care remains the second rank need followed by
psychosocial case management which is up from fourth in 2002.
Bus passes were the fourth ranked service in 2004. In 2002 bus passes were not
ranked, but taxi vouchers were ranked as the fifth most important service. Notably
when more transportation options were presented to the consumer in 2004, taxi
vouchers were ranked significantly lower, while bus passes were among the top five
most needed services.
Food pantry, part of the removal of barriers cluster, ranked fifth, with 69% of
PLWH/A saying they needed the service in the past year.
Nutritional education stayed in the top ten most needed services in 2004 with just
under 64% reporting a need for nutrition services in the past year.
There was a greater reported need for medication reimbursement in 2004 than 2002.
In 2004, 63% of PLWH/A said they needed medical reimbursement in the last year
and it was ranked as the 8
th
most needed service. In 2002 53% said they needed it in
the past year and it was ranked 11
th
.
Within the primary health care core, over 50% of the participants also said they
needed individual mental health counseling, visits to medical specialists, and
prevention information from the primary care giver.
In addition to the 4th ranked need for bus passes and 5
th
ranked need for food pantry,
other services needed by over 50% of the participants in the removal of barriers
cluster were independent housing and food vouchers.
Consumers reported a greater need for psychosocial case management than medical
case management. Still, over 56% of the participants reported needing medical case
management in the last year.
None of the services in the economic well being cluster or the enhancement
service were rated among the top twelve needs of the participants. There appeared
to be a significant decrease in perceived need for peer counseling in 2004 (44%)
compared to 2002 (54%), although this may be attributable to the different sampling
strategies used in the needs assessments.
Substance abuse services were reportedly needed the least by the participants. Given
the relatively low percentage of IDUs in the population of PLWH/A (14%, including
MSM/IDUs), this is not surprising. However, as seen in the later subgroup analysis,
even among drug users, the relative demand for substance abuse programs is low.
xxix
Figure 1 Service Needs

Primary Health Care
Core
0
%
20
%
40
%
60
%
80
%
100
%
%

P
L
W
H
/
A

PLWH/
A
95.1
%
77.6
%
63.9
%
63.2
%
58.7
%
57.9
%
54.5
%
39.3
%
35.7
%
35.3
%
23.3
%
18.2
%
17.6
%
14.0
%
11.4
%
10.9
%
6.4
%
Outp
t
me
d
Denta
l
Nutr
i
e
d
Me
d
reim
b
Ind
MH
Me
d
spe
c
Prev
@
Dr
.
HER
R
Ad
- her
e
Gr
p
M
H
Hom
e
hlt
h
Fa
m
cnslin
g
Re
s
M
H
Ou
t
SA
T
Re
s
SA
T
Hos
-
pic
e
Detox
/
Met
h
4
5
7
9
3
12
1
2
6
8
10
11
0
xxx
There are significant differences by subpopulations and these differences are fully discussed
in the Plan. Differences tended to be defined by socio-economic status, drug use behavior,
and cultural beliefs. All PLWH/A place outpatient care at the top of their lists, with case
management and dental care also among the top needs. MSM have a much greater focus on
services in the primary health care core. Poorer PLWH/A -- defined by gender, ethnicity or
risk group, like women, African Americans, and IDUs report a greater need for
transportation, food, and housing. Prevention is reported as a much higher need among
women and Hispanics. Substance users, both IDU and IDU/MSM tended to have a greater
need for mental health services particularly individual counseling. There are, however,
important differences I the needs of different populations. As shown in the table below,
when the top differences between MSM/IDU, IDU, and heterosexuals are listed, there are
some overlapping services, but each group is defined by their particular needs.

SUBPOPULATION DIFFERENCES MSM/IDU IDU HETEROSEXUAL
Outpatient substance abuse treatment !
Individual mental health counseling !
Workforce reentry !
Residential substance abuse treatment ! !
Detox / Methadone ! !
Buddy !
Bus Token !
Non-housing emergency financial
assistance
!
Transitional housing !
Group housing !
Spiritual counseling !
Housing information !
Treatment adherence ! !
Taxi voucher !
Prevention at doctors office !
Child care !
Translation !
Prevention education !

Service Gaps

The most important service gap measured was the difference between asking and receiving a
service. A significant ask-receive gap is an indicator that the system is not fulfilling the
expectation of the PLWH/A. In some instances, like emergency financial assistance for rent
and utilities and food vouchers, the expectation is unrealistic because CARE Act funds are
not allocated. In others, like nutritional supplements and dental care, some adjustments can
be made in the service delivery or allocation to better meet the needs of PLWH/A.

Notably for some services such as prevention and outpatient medical care, participants in H-
CAP report receiving more services than they asked for. This relates back to the earlier
comment that not all persons may need the level of services that the system mandates. The
gaps are shown in Figure 2 below.

xxxi
Figure 2: Ask-Receive Gap

Barriers to Receiving Services

PLWH/A reported individual, structural, and organizational barriers. As shown in Figure 3,
over 50% of PLWH/A say that they didnt knowing what treatment was available and 46%
say that their awareness of the location of service was a problem. For those mentioning these
barriers they were moderately high.

Fewer persons had structural barriers, but for those with them, they tended to be higher.
Between 30% and 40% of PLWH/A said that ability to pay, expressed in terms of insurance
or affordability, was a problem. However, for those with a problem it was a big problem.
Interestingly, relatively few PLWH/A (29%) said transportation was a problem, and for those
mentioning it, it was a moderate level barrier that did not rank among their top barriers.

Organizational barriers were ranked relatively low by PLWH/A. However, for the relatively
small percent who claimed feeling like a number (14%) or discrimination (6%) was a
problem, it was a big problem for them. The following chart displays the percentage of those
indicating structural, organizational, and individual barriers and the magnitude of those
barriers among those who named them.
-
25%
-
20%
-
15%
-
10%
-
5%
0
%
5
%
10
%
15
%
20
%
Ind
hsing
EFA rnt/util
Rent asst
Food
Vchr
Hsing
info
Denta
l
Nutri sppl
Lega
l
Taxi Vchr
Wrkfce
entry
Hme Dlvd
mls
Food
pantry
Nutri
ed
Med
CM
HER
R
Outpt med
care
Prev@Dr
.
Primary Health Care
COre
Removal of Barriers
Unfunded by RWCA Title
I
Patient Care Coordination
Economic Well-being
KEY
xxxii
Figure 3: Structural, Organizational, and Individual Barriers to Receiving Services

xxxiii
Vision of the Commission

The shared vision of the Commission remains constant: There will be 100% access to health
care with 0% disparities among the populations infected and affected by HIV and AIDS.
This will be accomplished through:
Multiple points of entry for clients to gain access to services with an expectation that,
regardless of entry point, the client will be assessed for need of primary health care core
services and referred to needed resources in a timely manner.
Improved integration, coordination, collaboration, and outreach between and among all
care and prevention service providers in both urban and rural areas of Los Angeles
County.
Maximizing Ryan White CARE Act funds through uniform intake and eligibility
screening processes and the subsequent coordination of care for PLWH/A that maximizes
non-emergency funds for providing quality and sustained HIV/AIDS care.
Reducing barriers to care, therein empowering PLWH/A to seek and access HIV/AIDS
prevention and care services without impediment of structural, language, literacy and/or
cultural disparities.

Goals

To achieve this vision in 2002 the Comprehensive Plan established a number of goals and
objectives. Substantial progress has been made on several, as shown in the table below and
detailed in the full Plan.

Table 1: Progress on 2002 Goals
2002 Comprehensive Care Goals Accomplishments
1. Within the next three years there is a
commitment by the Office of AIDS Programs
and Policy (OAPP), the Commission on HIV
Health Services (CHHS), and the Prevention
Planning Committee (PPC) to move toward
an integrated prevention and care services
continuum of service, and using a web-
enabled data collection and tracking system
to support that effort.
After considerable discussion, the merging of
the Commission and CPG was decided
against. However, there have been a number
of initiatives to better integrate prevention and
care including: 1) tracking of the newly
diagnosed, 2) OAPP contracts include
compensation for the costs of linked referral,
and 3) the data provided by HIV Epi for
behavioral risk groups (BRGs) is coordinated
with the epi data use for care. These are
discussed in greater detail below.
2. HIV reporting and the active follow-up of
those testing HIV positive is likely to
significantly reduce the number of PLWH
who are not in care and allow better
coordinated care for individuals in the
system.
Tracking newly diagnosed will be achieved
through the implementation of the HIV/AIDS
Interface Technology System (HITS) which has
been in development since 2002. When
implemented it will provide newly diagnosed
PLWH with direct access and entry into
medical outpatient care at the HIV counseling
and testing (HCT) entry point.
xxxiv
2002 Comprehensive Care Goals Accomplishments
3. With the implementation of HIV reporting
statewide, the Los Angeles Countys HIV
Epidemiology Program will be able to more
accurately track and describe the epidemic.
Once a person tested HIV positive, a system
will be implemented to encourage those in
care to seek care and stay in care.
HIV reporting was implemented in California in
July 2002, and HIV data can be considered
reliable and complete no earlier than July
2005.
4. Further development and implementation of
standards of care, quality assurance,
outcomes and indicators for services will
increasingly play an integral role in the
monitoring process.
Continuous quality improvement processes will
be implemented to ensure ongoing updates to
standards, outcomes and indicators and to
achieve best practices in HIV service delivery.
5. The Commission will separate from OAPP
oversight, and, in so doing, will engage its
own professional support staff to carry out
its responsibilities.
The move of the Commission from OAPP in
the Department of Health Services to the
Board of Supervisors was achieved in 2004.
The new Executive Director and professional
staff of the Commission bring a dedicated level
of service to the volunteer Commissioners.
6. The Commission will undertake a more
comprehensive ongoing needs assessment
process by adopting a continuous data
collection model that utilizes ongoing data
collection tools, as well as specialized needs
assessment studies where data is lacking
and further research needed.
The Commission has implemented the
HIV/AIDS Care Assessment Project (H-CAP)
that provides input from PLWH/A into the
planning process.
7. Service planning will be done at the SPA
and potentially at the sub-SPA
neighborhood level in order to reflect the
different needs of communities throughout
Los Angeles County. Service Provider
Networks (SPN)--and the Coordinated
Prevention Networks (CPNs) (as described
in the Prevention HIV Prevention
Cooperative Agreement for 2002) will lead
these efforts with support from OAPP and
the Commission.
The SPNs have been initiated in each of the 8
SPAs. The SPNs bring together many service
providers, both Ryan White CARE Act funded
and not, within the SPA to promote
collaboration networking and partnership in
HIV service delivery.

Goals for 2005-2008

For the next three years the Plan highlights a set of fifteen different goals, and establishes
tasks to accomplish them and tools to monitor their progress. They are divided by those
relating to service delivery, those related to planning, and those promoting the infrastructure
needed to improve the Continuum of HIV/AIDS Care. The fifteen goals are shown below
and the specific objectives and timetable for their completion is shown in the full Plan.
xxxv
Table 2: 2005-2008 Goals
SERVICE DELIVERY GOALS
1. Disseminating the Continuum of Care to PLWH/A and consumers to increase
knowledge about the prioritization of services and their availability.
2. Assuring Access to Early Intervention Services
3. By 2006 Providers will use a Standard Intake Form and procedure
4. Confronting discrimination and encouraging public support
5. Secure services in accordance with the continuum of care and its five priority areas.
6. Standards and outcomes will be established for every service category and written
into contract language by OAPP.
7. By 2007 unit costs and cost reimbursement will be in place for all CARE funded
services.
8. The Commission will establish benchmarks for the Administrative Mechanism.
PLANNING GOALS
9. Develop a Los Angeles County Continuum of HIV Services that will incorporate
care and prevention services to allow a seamless integration of detection, early
intervention, and sustained care.
10. Epidemiological, consumer, and patient data will be used to plan for the best
combination of services and used to allocate funds to services.
11. Targeted population planning and use of targeted funds
12. Data for Decision Making
INFRASTRUCTURE GOALS
13. Shared information on clients to reduce red tape, facilitate access to services,
determine eligibility, and the health status of patients.
14. Identify alternate sources of funding to enhance local HIV service delivery
systems.
15. Improving Consumer Satisfaction

Last Word

In 2004, over 20 years into the epidemic, some born with HIV are now adolescents and the vast
majority of people living with AIDS are middle age, and many are in their 50s. Latinos make
the plurality of those living with HIV and AIDS. African Americans are disproportionately
infected, and MSM continue to represent over three-quarters of those infected with HIV and
AIDS.

While the spotlight is often on younger PLWH/A, and the rates of infection among young gay
men are disturbingly high, the vast majority of those needing and seeking care are older. As
mortality continues to decline and people are living with AIDS for fifteen or more years, one
challenge is how to best coordinate the general health care needs of PLWH/A with their
xxxvi
HIV/AIDS service needs. Among long term survivors understanding and treating the side-
effects of toxic medication regimens will add to the complexity of treating HIV infection.

Organizationally there has been a greater emphasis on planning and establishing uniform
standards of HIV and AIDS care. This was facilitated by the move of the Commission to the
Board of Supervisors from the Department of Health Services Office of AIDS Programs and
Policy (OAPP).

A primary objective of the Commission has been to include PLWH/A in the planning process
and the HIV/AIDS Care Assessment Project (H-CAP), started in 2003 by the Commission,
systematically collects and analyzes care needs, gaps, and barrier information from PLWH/A.
The Commission has also implemented a more rigorous and formal priorities and planning
process.

For the grantee, this past year and upcoming year will show the results of re-bidding the services
offered in the continuum of care, thus starting with new contracts for services among those with
past experience and some new providers. Over the next few years the system will move to cost
reimbursement based on uniform unit costs.

While each of these changes promise improved services for PLWH/A through more rigorous
standards and quality management, the system will be absorbing these changes over the next few
years. They will require more sophisticated systems, close collaboration of the partners in the
administrative mechanism, and clear understanding of the continuum among PLWH/A and
providers. Past experience demonstrates that bringing new systems into the process is difficult
and challenging. This Plan recognizes that HIV/AIDS is likely to be with us for many more
years. Los Angeles has handled the crisis with great success. Now the challenge will be to
incorporate HIV/AIDS care into the overall health care system as it becomes a chronic disease
that needs long term and expensive management with increasingly limited resources.

xxxvii
INTRODUCTION

This update of the 2002 County of Los Angeles HIV/AIDS Comprehensive Care Plan is a major
revision. Epidemiologic estimates have been updated through June 2004. Consumer service
needs, gaps, and barriers reflect data collected from spring through winter 2004. A new leading
section, The Face of AIDS presents composites of nine key subpopulations based on much of
the information in the Plan.

In 2004, over 20 years into the epidemic, some born with HIV are now adolescents and the vast
majority of people living with AIDS are middle age, and many are in their 50s. The number of
Latinos moving to the LA area continues to grow and now represent 46% of the population, and
the HIV epidemic continues to shift more to the Latino and African American communities. Of
the estimated 43,454 people living with HIV and AIDS (PLWH/A) who are aware of their
infection, 40% are Latino, 32% are Anglo, and 24% are African Americans. African Americans
who represents are 9.5% of the population have a much higher rate of HIV infection and AIDS
than any other ethnic community.

While the spotlight is often on younger PLWH/A, and the rates of infection among young gay
men are disturbingly high, the vast majority of those needing and seeking care are older. As
mortality continues to decline and people are living with AIDS for ten or more years, one
challenge is how to best coordination the general health care needs of PLWH/A with their
HIV/AIDS service needs. Among long term survivors understanding and treating the side-
effects of toxic medication regimens will add to the complexity of treating HIV infection.

Organizationally there has been a greater emphasis on planning and establishing uniform
standards of HIV and AIDS care. This was facilitated by the move of the Commission on HIV
Health Care Services (Commission) to the Board of Supervisors from the Department of Health
Services Office of AIDS Programs and Policy (OAPP). A primary objective of the Commission
is to include PLWH/A in the planning process and the HIV/AIDS Care Assessment Project (H-
CAP), started in 2003 by the Commission, which systematically collects and analyzes care
needs, gaps, and barrier information from PLWH/A.

The past two years has not seen major advances in curing AIDS. Medications to control the
virus have steadily advanced, making managing HIV easier and more effective. But no cure has
been discovered, and the cost of an effective medical regimen continues to be high. While the
number of PLWH/A continues to increase, The Health Resources and Services Administration
(HRSA), the federal agency that administers the Ryan White CARE Act, has decreased the 2004
funding level from about $42 million to $39 million. At the same time a sluggish economy has
made it more difficult for community based care providers to raise contributions.

In short, there is a growing demand for CARE Act funded HIV and AIDS care services, as
mortality continues to decline and the number of PLWH/A without insurance increases. If this
challenge is to be met, it is critical to have a planning process that identifies and prioritizes the
care needs, maximizes the use of funding sources other than CARE Act funds, and provides clear
standards for quality care.
xxxviii

In 2002, The Los Angeles County HIV/AIDS Comprehensive Care Plan (Plan) presented a road
map of the Countys response to HIV/AIDS epidemic. This updated plan continues to describe
the journey made by the Commission and its partners to address the service needs of PLWH/A,
while presenting future routes for meeting its mission of:
Decreasing HIV/AIDS mortality and morbidity.
Improving the quality and availability of comprehensive HIV/AIDS-related services to needy
individuals and families.
Collaborating with other HIV/AIDS services organizations to assess and identify emerging
HIV/AIDS services delivery needs.
Facilitating a coordinated and community-based viable regional voice for HIV-impacted
populations.

How the Plan is Organized

The first section of this Plan reviews the history of the HIV/AIDS epidemic in Los Angeles
County (LAC). This section:
Reviews the overall context of the Plan by describing the vision and values of the
Commission, and its continuum of HIV/AIDS care.
Provides an overview of economic, social and health indicators in the LA EMA and its
Service Planning Area (SPAs).
1

Summarizes the epidemiology of the HIV/AIDS epidemic in Los Angeles County and
highlights the diverse linguistic and cultural heritages of the various populations affected by
the epidemic, including composites of PLWH/A in each Service Planning Area (SPA). The
epidemiology focuses on people living with HIV/AIDS, as this will be the population that
must be served by the continuum of HIV/AIDS care. This section has been updated to
include PLWH/A through June 2004.
Estimates the number of PLWH/A who are not in care.
Profiles the new infections and discusses trends in the epidemic.
Describes HIV within a larger fabric of community needs, and discusses how the co-
morbidities of drug use, homelessness, STDs, mental illness, and poverty intersect and affect
the HIV/AIDS service needs of PLWH/A.
Summarizes the needs, unmet needs, service gaps, barriers, and disparities to services
confronting PLWH/A based on a 2004 needs assessment survey, focus groups and supporting
data from a variety of empirical studies and economic analyses. The needs of different ethnic
and risk group subpopulations are presented, highlighting the needs and barriers of the nine
target populations
2
.
Reviews the services available for PLWH/A in Los Angeles County.
Provides a service provider profile indicating locations and current utilization of services.

1
The County of Los Angeles is divided into eight Service Planning Areas (SPAs) that are used for health planning purpose. They are discussed
throughout the report. This section is not updated from 2002.
2
1) Men of Color who have sex with men, 2) Recently Incarcerated, 3) Undocumented, 4) MSM, 5) Latino/as or Hispanics, 6) Severely Mentally
Ill, 7) Women of Child bearing age (18-49), 8) Homeless, 9) Youth (18-24)
xxxix

The second section details the route to be traveled to reach the Commissions goals and
objectives for HIV/AIDS services in Los Angeles County. This section:
Summarizes the strategic planning process undertaken by the EMAs Core Planning Partners
[the Commission, the Office of AIDS Programs and Policy (OAPP), and the Select
Committee on Prevention Planning (PPC)].
Outlines core competencies and weaknesses of the care services system.
Delineates the HIV/AIDS service systems primary goals and objectives for the next three
years.
Proposes how Ryan White CARE Act funds can fill critical gaps in the continuum of care or
be used to build bridges to existing services that may meet complementary needs of
PLWH/A--such as substance abuse or housing--which need to be more sensitive to the
specific needs of PLWH/A.
Recommends budget priorities and allocations for key services, as well as for systemic
program support and planning council (Commission) support.

The final section discusses how the Commission and OAPP will monitor the progress and
outcomes of the Comprehensive Care Plan. For each objective, mechanisms to monitor the
process and measure outcomes are discussed. As work continues on the Plan, data sources and
indicators will be developed, benchmarks noted where data is available, and if not available, data
that is needed for benchmarks and subsequent measurements of progress will be identified. Both
quantitative and qualitative measures are discussed.

Methodology

HIV/AIDS Care Assessment Project: Questionnaire and Focus Groups (H-CAP)

This updated Plan reflects a significant improvement in the methodology used to collect data on
the service needs, barriers, and gaps of PLWH/A. The primary source of the needs data in 2002
were 30 community forums where 308 PLWH/A participated in interviews and/or focus
discussion sessions. A needs assessment survey was completed by 246 PLWH/A who were
recruited by their providers or heard about the forums through leaflets or other advertisements.
The community forums were held in each service planning area (SPA), with twenty-one out of
twenty-six forums done in April 2002. Five other forums were completed from May through
July 2002. The constraints in 2002 was the unknown representativeness of the sample, the small
time frame for interviewing, and the small sample size.

In 2003, these constraints were addressed. The Commission and OAPP worked together to
establish the HIV/AIDS Care Assessment Project (H-CAP), a continuous data collection process
where a proposed 825 PLWH/A are randomly recruited and surveyed based on a stratified
sampling plan and interviewed throughout the year. Each year the survey is supplemented by
eight to ten focus groups on special subjects. H-CAP measures the care needs and barriers of
participants, and updates their demographic profile, incidence of co-morbidities (such as
substance use, homelessness, STDs, and mental illness), and measures their physical and
xl
emotional health. H-CAP is a multi-year needs assessment where participants are re-interviewed
each year. Those who withdraw from the sample are replaced by new participants. The
longitudinal design allows for the analysis of trends at an aggregate and individual level.

Providers are the primary source of recruitment for survey participants because laws restrict
direct access to personal information about PLWH/A and providers have established a rapport
with their clients which facilitates recruitment. H-CAP establishes a protocol for providers to
randomly sample clients to limit sampling bias. Provider recruitment is supplemented by direct
outreach efforts for out-of-care and difficult to reach populations.

H-CAP planning and discussion began in August 2003. The IRB applications for the two
components of H-CAP, Questionnaires (H-CAP:Q) and Focus Groups (H-CAP:FG), were
submitted to the Department of Health IRB in December 2003 and February 2004, respectively.
H-CAP:Q was given final approval in April 2004 and H-CAP: FG was exempted from review.
Due to a lengthy IRB process and difficulties in establishing recruiting procedures during the
start-up, 732 PWLH/A were interviewed in 2004 rather than the expected 825.

Sampling

PLWH/A are recruited based on a stratified random sample plan shown in Table 1-1. All
respondents must be HIV positive and over 18 years of age. The stratification is based on a
matrix which includes ethnicity, risk group, and gender. It also includes special need
populations. Most special need populations are accounted for by chance when participants are
recruited using the stratified random sampling protocol, but certain populations such as out-of-
care, youth, and Native American participants are separately recruited.

A stratified random sample is used to assure that different populations have sufficient sample
size for analysis. Consequently women-of-childbearing age, heterosexuals, IDU, youth, Native
American, transgender, and undocumented clients are over-sampled relative to their proportion
in the population of PLWH/A. While they are weighted back to their population proportion in
the analysis of all PLWH/A, this sampling strategy allows more accurate subpopulation analysis.
xli
Table 1-1 Sample Quotas by Ethnicity and Gender
Anglo Af Am Latino API Other/Mixed
Male Female Male Female Male Female Male Female Male Female TOTAL
MSM* 50 NA 50 NA 70 NA 35 NA 10 NA 215
MSM/IDU 40 NA 20 NA 30 NA 10 NA 0 NA 100
IDU 30 25 50 45 20 25 10 5 0 0 210
Heterosexual* 30 45 30 50 30 45 5 5 5 5 250
TOTAL 150 70 150 95 150 70 60 10 15 5 775
Special populations
Transgender To be recruited separately 25
Native American To be recruited separately 25
Special pops below this line are included in above sample
Youth (18-24) Will recruit specifically for youth within populations above 40
Non Injection Drug Users (IDU) Estimate of at least 50% of sample 462
MSM of Color (MSMC) Included above in African-American, Latino, and API MSM. 165
MSM and Women (bisexual/ MSMW) Estimate from HIV Epi at 7.5% of PLWH/A. 60
Women of Childbearing Age (WOCBA) Estimated 90% of all women 225
Seriously Mentally Ill (SMI)* Estimated at more than 20% of recruited pop. 160
Recently Incarcerated (w/in past 2 yrs) Estimated at least 25% of sample 200
Undocumented
Will recruit specifically for undocumented within populations
above 30
Homeless / unstable housing Estimated about 15% of recruited population. 120
Out-of-Care (12 mo. W/out medical care) Recruited through outreach 100
TOTAL 825
* Severely mentally ill is a HRSA special need population and defined as the participant reporting a history of being an
inpatient or using prescribed medication for a mental illness.

Recruitment

All CARE Act funded providers of care services were contacted to assist in the recruitment.
Fifty-five agencies were asked to assist in recruitment, and thirty-six agencies participated.
Their motivations were:
The value of the project in assuring continued funding for HIV services.
The burden is small for each provider.
At the conclusion of each project year, providers are compensated $8.00 for each client they
recruit who participated.
Providers are required to help collect needs assessment data as part of their OAPP contract.

Provider staff was asked to recruit twice the number of persons expected to be interviewed in
each stratum noted in Table 1-1 because of an estimated refusal rate of 50%, among those who
agree to participate. Each provider was assigned a stratified quota based on race, gender, and
risk group. The quota was determined based on the proportion of overall clients seen according
to the OAPP client database, IMACS/Casewatch. In 2004, providers were asked to recruit the
participants during three periods over six months.

The flow of the recruitment process effort is shown in Figure 1-1.
xlii
Figure 1-1 Recruitment Process

To comply with the IRB and to assure that all recruiters recognized the rights of the participants,
before starting, all recruiters had to sign a confidentiality agreement and complete two online
courses offered by UCLA: 1) Protecting Human Research Subjects in Social and Behavioral
Research and 2) HIPAA Clinical Research Training Course. Once recruited providers completed
a screening form with basic contact information that was given to H-CAP staff, and H-CAP staff
contacted the recruit to complete the interview. Recruiters noted on the screening form if the
recruit agreed to complete the survey, participate in a focus group, or both. Copies of signed
informed consent and HIPAA authorization forms and the screening form were given to H-CAP
staff. Unless the recruit contacted H-CAP staff using the toll free number provided within a few
days, H-CAP staff contacted the recruit to conduct the survey over the phone, schedule a
personal interview, or provide further instructions on how to complete a survey online.
Depending on the demographics of the recruit he or she may have been asked to participate in a
focus group.

In early April 2004, a letter was sent to each executive director (or equivalent) soliciting the
organizations assistance. The letter asked that a primary and secondary recruiter from the
organization be identified to receive training and supervision by H-CAP staff to conduct
recruitment for that agency.

On April 19, 2004 two trainings were held for recruiters. A full training packet is available from
the Commission. Ninety-four (94) recruiters representing over 55 agencies attended the
trainings. In addition, 51 staff members of OAPP and three members of the Commission
attended. The training reviewed the logistics of the recruitment process including how to:
Randomly select participants.
Provider Recruiter
Sign confidentiality statement.
Complete HIPAA Course and Protecting
Human Research Subjects.
Randomly select PLWH/A.
Recruit participants for survey and focus
groups.
Fill out
refusal
form.
Administer Informed
Consent and HIPAA
Authorization Form.
Complete screening form.
Hand out enrollment kit.
H-CAP Staff
Train recruiters.
Confirm participation.
Arrange logistics for participation
(transportation, day care).
Interview in-person or phone.
Help desk for those who complete
the survey on-line.
Data entry & analysis.
Report findings.
xliii
Administer and complete the informed consent and HIPAA Authorization forms.
Complete the screening and refusal forms.

For new provider recruiters that were assigned after the training, materials were provided on the
PCH website and telephone conference trainings were arranged.

Consumer Survey

Using the 2002 needs assessment survey as a referent, the 2004 survey was designed by PCH
and, after input from OAPP, Commission, and P&P members, it was approved in December
2003. The survey was designed in English and Spanish. The final consumer survey is shown in
Attachment 1.

The first section of the questionnaire captures key demographics, insurance and benefits
information, stages of HIV disease progression, medications and adherence, and self assessments
of physical and emotional health. Question 36 measures current awareness, need, demand,
receipt, and utilization of 44 services included in the LA County continuum of HIV/AIDS care.
Question 37 measures service barriers and the degree to which it caused a problem for the
respondent. Each year a special topic is selected to explore in greater detail on the survey. In
2004 Prevention for Positives was chosen by the Commission. These questions involved
measurements of their sexual and drug use behavior as well as attitudes toward prevention
messages.
3

The survey was designed to be interviewer-assisted, conducted over the telephone, or completed
through the Internet.

Phone Protocol

Because of the confidentiality of the interviews, all phone interviews were completed from
central phone facilities located at PCH offices in New York with professional interviewers. All
interviewers were trained using a prepared curriculum that included practice sessions.
Interviews were monitored by supervisory staff. All interviewers were required to complete the
online research and HIPAA courses and signed a confidentiality agreement, which assures they
understand that they cannot discuss any participant or their responses except as needed with H-
CAP staff.

Interviewers contacted and scheduled interviews from screening sheet information. The status of
each contact was recorded and recruits were called back until a deposition had been determined.
Interviews were done in Spanish or English.

Because of the multiple recruitment and survey methods, confidential IDs on the completed
interviews were checked and if a duplicate was found, the telephone interviewer asked the
participant if he or she had completed a questionnaire in the past. If the interviewer determined

3
This section was derived from questions asked in a Long Beach Prevention for Positives Needs Assessment conducted by PCH in 2003-2204.
xliv
it was a duplicate, the interview was politely terminated. If no determination was made the
interview was conducted and flagged for further follow-up during data verification and cleaning.

Interviewer Assisted Face-to-face and Group Protocol

Personal interviewers were hired and trained in Los Angeles. Like telephone interviewers, they
completed the online research and HIPAA courses and signed a confidentiality agreement.
The H-CAP Field Coordinator scheduled either one-on-one or self-administered interviews
during a group session. Upon completion, the questionnaires were shipped to PCH in New York
using overnight mail and tracking numbers in case of shipping difficulty. Only confidential IDs
were shown on the questionnaires; there were no names or other identifying information on the
questionnaires.

For the group interviews, flyers were distributed in the clinics. PLWH/A who came were given
the Informed Consent Form, the HIPAA Authorization Form, the Screening Form, and a
questionnaire in either English or Spanish. Interviewers were available to help participants with
any questions or to assist illiterate respondents. Interviewers checked each questionnaire for
completeness. Table 1-2 shows the locations and the dates of group interview sessions. About
ten interviews were completed using the online survey.

Table 1-2 Open Recruitment Sessions
DATE Location TIME # Attended
1 10/21/2004 AHF Downtown 8:30am- 3pm 23
2 10/25/2004 High Desert 10:00am-noon 16
3 10/25/2004 Rand Schrader 11:00am- 6pm 61
4 10/25/2004 Los Angeles Gay and Lesbian Center 1pm- 5pm 2
5 10/26/2004 Charles Drew University 9:00am- 4:30pm 51
6 10/26/2004 Van Ness Recovery House 3:00pm- 5:00pm 8
7 10/27/2004 AHF Hollywood 8:00am- 6:00pm 42
8 10/27/2004 St. Marys 5:00pm- 8:00pm 52
9 10/28/2004 AltaMed 9:00am- 5:00pm 28
10 10/28/2004 Serra House (3 locations) Throughout 9

Online Interviewing

Recruits were given the opportunity to complete the questionnaire online if they had access to
the Internet. The questionnaire was initially designed in SPSS Data Entry Web Server and later
transferred to MrInterview
4
. Participants accessed the online questionnaire through PCHs web
page. They used their confidential to access the survey.

Once in the system, respondents follow the prompts on the screen to complete the questionnaire
in either English or Spanish. It automatically moves through the appropriate skip sequence
depending on responses. At the end of the online questionnaire, participants are notified that
once responses are verified compensation is mailed. There is a help line at PCH to assist
participants with the questionnaire if they have any technical problems or are unable to fully

4
For details on MrInterview link to http://www.spss.com/mrInterview/.
xlv
comprehend the questions being asked. Participant responses go directly to a web server located
at PCH offices.

To assure confidentiality, the server has a firewall, and the information is encrypted. The survey
is accessed through an SSL protocol to manage the security of message transmission on the
Internet. The SSL protocol utilizes the HTTPS (Secure Hypertext Transfer Protocol). The
survey site is authenticated by Thwate, which provides a digital certificate to PCH that assures
that the site is secure. The security used for the online survey is similar to the system many
commercial Internet providers use to secure financial transactions. The only identifying
information on the questionnaire is the confidential ID and it cannot be linked to any name. A
backup of the information is made daily, and weekly back-ups are kept off-site in a secure
location.

Response Rate

In 2004, providers recruited 958 PLWH/A, and H-CAP interviewed 732 for a completion rate of
76%. About 400 interviews were completed over the telephone by H-CAP staff. These sessions
ranged from 30 minutes to 2 hours. Thirty-five interviews were one-on-one sessions, and 292
were completed in group settings run by H-CAP staff at specific agencies.

The final number of respondents fell short of the 825 goal. Reasons for the lower than expected
participation were: 1) technical difficulties with the online software which was changed mid-way
through the process to make it more stable and easier to use, 2) the unanticipated need for several
University and Hospital based providers to complete their own IRB, 3) the significant start-up
time it took before interviewing began in April 2004, 4) the unavailability of the online interview
until late in the survey process and 5) the lack of provider recruiter time to complete
recruitment.. Table 1-3 shows how the final sample compares to the quota sample plan.
Recruiters oversampled MSM and Latino males in general and females and APIs were under-
recruited. Still, the overall sample sizes of most risk groups are adequate for analysis.

xlvi
Table 1-3 Final Sample
Risk Group Race Group Sample Quotas Unweighted N=732
Male MSM Anglo 50 57
Af Am 50 98
Latino 70 149
API+ other 45 23
Male MSM/IDU Anglo 40 37
Af Am 20 24
Latino 30 41
API+ other 10 12
Male IDU Anglo 30 14
Af Am 50 27
Latino 20 16
API+ other 10 3
Male Het Anglo 30 4
Af Am 30 25
Latino 30 39
API+ other 10 0
Fem IDU Anglo 25 8
Af Am 45 14
Latino 25 7
API+ other 5 6
Fem Het: Anglo 45 6
Af Am 50 52
Latino 45 60
API+ other 10 10
Populations with Special Needs
1

Non Injection Drug Users - NIDU 462 347
Women of child-bearing age - WOCBA 225 78
MSM of Color 165 395
Men-who-have-sex-with-men-and women
(MSMW) 60 118
Youth (18-24)
3
40 24
Undocumented 30 128
Transgender 25 32
Out-of-care 100 12
Homeless / unstable housing 120 34
Seriously Mentally Ill (SMI)
2
160 351
Native American 25 4
Recently Incarcerated 200 79
1. Special need populations are defined in the Ryan White Care Act Title I application for 2003-2004 (before it
said 2004-2005), with the exception of Native American. These populations are not mutually exclusive.
2. In planning Ryan White CARE funded services, seriously mentally ill is defined as any person who in the last
two years has had a diagnosis of depression, dementia, or bipolar disorder and has taken medication for
psychological or behavioral problems. Those institutionalized for mental illness are not included in the sample.
3. Youth are defined by HRSA as 13 to 24 years of age, but this questionnaire will only be administered to those
youth between the 18 and 24.
xlvii
Analysis

The survey data was analyzed using SPSS, a statistical software package. Weights were applied
to the oversampled populations to bring them back to the estimated population proportion. The
weighted and unweighted sample is shown in Table 1-4 with actual sample recruited in the
unweighted column and the results of the weighted sample in the weighted column. This
process allows for an analysis of the data that that represents all PLWH/A.

Table 1-4 Sample Quotas by Ethnicity and Gender vs. Unweighted and Weighted N=732
Risk Group Race Group Unweighted
N=732
% Unwted Weighted
N=732
%
Wted
MSM White 57 7.8% 191 26.1%
Af Am 98 13.4% 101 13.8%
Latino 149 20.4% 216 29.5%
API+ other 23 3.1% 16 2.1%
MSM/IDU White 37 5.1% 20 2.7%
Af Am 24 3.3% 12 1.7%
Latino 41 5.6% 13 1.8%
API+ other 12 1.6% 1 .2%
Male IDU White 14 1.9% 12 1.6%
Af Am 27 3.7% 15 2.0%
Latino 16 2.2% 15 2.0%
API+ other 3 0.4% 0 .0%
Male Het White 4 0.5% 3 .4%
Af Am 25 3.4% 8 1.2%
Latino 39 5.3% 13 1.8%
API+ other 0 0.0% 0 .0%
Fem IDU White 8 1.1% 6 .8%
Af Am 14 1.9% 9 1.2%
Latino 7 1.0% 5 .7%
API+ other 6 0.8% 0 .0%
Fem Het: White 6 0.8% 11 1.5%
Af Am 52 7.1% 27 3.7%
Latino 60 8.2% 32 4.4%
API+ other 10 1.4% 3 .4%
Populations with Special Needs
1

Non Injection Drug Users - NIDU 163 22.3% 229 31.3%
Women of child-bearing age - WOCBA 112 15.3% 80 11.0%
MSM of Color 268 36.6% 332 45.4%
Men-who-have-sex-with-men-and
women (MSMW) 103 14.1% 112 15.3%
Youth (18-24)
3
16 2.2% 26 3.5%
Undocumented 115 15.7% 123 16.8%
Transgender 36 4.9% 33 4.5%
Out-of-care 12 1.7% 9 1.3%
Homeless / unstable housing 31 4.2% 31 4.2%
Seriously Mentally Ill (SMI)
2
358 48.9% 358 48.9%
Native American 13 1.8% 3 0.4%
Recently Incarcerated 94 12.8% 83 11.3%

The analysis of all PLWH/A will have a margin of error of about plus or minus 3.5%. That is, if
50% of the PLWH/A report making $9,000 or less in the survey, in reality anywhere from
46.5% to 53.5% may make $9,000. The data is also analyzed by each subpopulation. In most
cases these subpopulations are represented by more than 100 respondents and the level of error
for these subpopulations is usually about plus or minus 10%. The quota sample was designed to
xlviii
oversample some of these populations like Native Americans, undocumented individuals,
women, and youth in order to allow subpopulation analysis. These oversampled populations
were weighted back to their proportionate representation in the analysis. Confidence intervals
may approach plus or minus 20% for subpopulations with 25 or less respondents and reported
findings may not be generalizable.

Focus Groups

Eight focus groups were conducted in 2004. Focus groups were used to explore in greater depth
consumers perceptions of needs, gaps, barriers and disparities. Focus group topics in 2004
included HIV/AIDS care needs among 1) African American men, 2) African American women,
3) Latino men (two groups), 4) Latino women, 5) out-of-care, and 6) men-who-have-sex-with-
men and women. Two of the Latino groups were held in Spanish. PCH moderators conducted
the groups following the outline shown in Attachment 2. The out-of-care group had a different
outline to include their specific needs, shown in Attachment 3. The schedule of focus groups is
shown in Table 1-5.

Table 1-5 Focus Groups
DATE LOCATION GROUP
6/22/2004 Commission Offices African American Women
6/22/2004 Commission Offices African American Men
6/23/2004 Commission Offices Latino Men (2 groups)
6/23/2004 Commission Offices Latina Women
6/24/2004 Miller Education Center, Long Beach Out-of-Care (2 groups)
10/28/2004 Commission Offices MSM/W

In the following report comments extracted from the transcripts can be found, and they are used
to illustrate the findings from the quantitative information of the survey and highlights areas of
concern mentioned by PLWH/A that was not apparent in the analysis of the survey information.

Compensation

Participants received food vouchers valued at $20. In the following years of H-CAP, participants
who agree to be re-interviewed will receive $30 the second year, and if they agree to continue in
H-CAP will receive $40 in subsequent years. All focus group participants received $20 for their
participation. Providers received $8 for each recruit they referred that resulted in a completed
interview.

Data Sources

In addition to the H-CAP survey and focus groups, various data sources were referenced,
reviewed and interpreted for this report. The HARS (HIV/AIDS Reporting System) database
was used to analyze AIDS trends and current epidemiology of PLWH/A. The OAPP client
utilization data collection system (IMACS and Casewatch) was a source for the presentation of
demographic trends and service utilization of PLWH/A in Los Angeles County. In addition,
several secondary sources and publication were reviewed and these can be seen in Attachment 4.

1-1
1. WHERE ARE WE NOW

MISSION OF THE COMMISSION

To achieve the Commissions vision, its mission is to provide effective planning and evaluation
of Los Angeles Countys HIV/AIDS services delivery systems that improves PLWH/A health
outcomes and quality of life in compliance with the Health Resources and Services
Administration (HRSA) planning requirements. The Commissions work is intended to comply
with Ryan White CARE Act legislative requirements.

VISION AND VALUES OF THE COMMISSION

The shared vision of the Commission is an HIV/AIDS Continuum of Care that will assure 100%
access to health care with 0% disparities among the populations infected and affected by HIV
and AIDS. This will be accomplished through:
Multiple points of entry for clients to gain access to services with an expectation that,
regardless of entry point, the client will be assessed for need of primary health care core
services and referred to needed resources in a timely manner.
Improved integration, coordination, collaboration, and outreach between and among all care
and prevention service providers in both urban and rural areas of Los Angeles County.
Maximizing Ryan White CARE Act funds through uniform intake and eligibility screening
processes and the subsequent coordination of care for PLWH/A that maximizes non-
emergency funds for providing quality and sustained HIV/AIDS care.
Reducing barriers to care, therein empowering PLWH/A to seek and access HIV/AIDS
prevention and care services without impediment of structural, language, literacy and/or
cultural disparities.

Several values guide the vision and mission of the Commission and its implementation of the
HIV/AIDS Comprehensive Care Plan. They include:
Los Angeles Countys HIV/AIDS continuum of care should be characterized by innovative,
high quality service delivery that improves the health status and quality of life of PLWH/A.
Services should be available to the diverse populations of PLWH/A throughout Los Angeles
County based on need and not the ability to pay.
Services should be cost-effective and cost-efficient.
Services should be accessible to all PLWH/A, along with assurances that those who are
eligible can access CARE Act-funded care.
PLWH/A should have a clear voice in the planning of their services.
Resources should be fairly and equitably distributed throughout Los Angeles County.
Ethical practices should guide the funding and delivery of services.
Service delivery should be attentive to maintaining the dignity of PLWH/A. They should be:
Culturally and linguistically appropriate.
Compassionate
1-2
Respectful.

Regional Planning

In 1996, eight Service Planning Areas (SPAs) were created within Los Angeles County (Figure
1-1). Each SPA has a Coordinating Council that collects and analyzes local data. A brief
geographic description of each area is provided in Attachment 5.

The Commission has adopted the SPA as the major unit for HIV/AIDS health care planning.
Service Provider Networks (SPN)see Attachment 6--and the Coordinated Prevention Networks
(CPNs) assist in coordinating care and prevention efforts with support from OAPP and the
Commission.

Figure 1-1 SPA Map

6.
South
8. South Bay
5. West
2. San Fernando
4. Metro
1. Antelope Valley
7. East
3. San Gabriel
1-3
CONTINUUM OF CARE

The Commission adopted a new continuum of care in 2001 and has continued to refine it to
reflect the needs of PLWH/A. In 2002 the Commission made Removal of Barriers the second
priority, and Patient Coordination and Language Care services the third priority. Within the five
groups of services, the Commission moved medical case management from Removal of Barriers
to Patient Care Coordination.

The Continuum has become an important tool in the prioritization and allocation process as
services are organized and funded in the category grouping outlined in the continuum of care.
Conceptually, the continuum is composed of a core of primary health services surrounded by
wrap-around services which enable PLWH/A to access and fully utilize services in the primary
health care core.
The highest priority services are in the primary health care core which includes medical
outpatient services, dental care, nutritional counseling, mental health services, substance
abuse services, end-stage hospice care and patient education, counseling and testing,
treatment adherence services, health education/risk reduction education, and other prevention
efforts.
The second level priority services are the Removal of Barriers Services. The services in this
cluster optimize critical paths through access, utilization, retention, transportation, child
care, housing, food services, and client advocacy. These key services provide low-income
PLWH/A access to care which meets their basic needs and that allow them to focus on their
HIV primary health care. Studies have shown that PLWH/A who do not have their basic
housing and nutritional needs met, or who have no or poor transportation to services, are
unlikely to seek and maintain primary health care.
The third priority services are located in the Patient Care Coordination cluster of services.
These services offer PLWH/A a choice in care coordination approaches (patient care
coordinators, nurse case managers, and/or medical case management and language services
for non- or limited English proficiency populations. Patient care coordination services
respond to the complexity of the health care system and by providing expert guidance in to
clients seeking and accessing services provided in the continuum of care. Case management
is viewed as critical to assisting PLWH/A obtain and maintain their proper regimens of care.
As the medical regimens become more varied, complicated, and complex medical case
management is necessary. For those who do not speak English or who experience difficulties
with English comprehension, translation and interpretation services are an essential factor in
patient care coordination.
The fourth priority services are located in the Economic Well-Being cluster of services that
create direct, working, effective linkages and collaborations with services and community
developments related to amelioration of poverty, workforce re-entry services, health
insurance (and other benefits) access and continuation of services. Economic well-being
measures include legal services and permanency planning. Both of these types of services
significantly impact the continuity of care for families, in particular addressing the needs of
HIV-positive and -negative children of parents who are HIV positive.
1-4
The fifth priority services are in the Enhancement Services cluster. These services, including
psychosocial support from peers, and other supportive social services are designed to
enhance the core and wrap-around services, and the quality of life for PLWH/AIDS. The
wrap-around and self-enhancement services are intended to mitigate disparities in care and
ensure client access to appropriate primary health care services. Self-enhancement services
improve clients quality of life through activities such as self-help services, peer support,
buddy companion services, and pastoral care.
The sixth priority of services is program support. In order to manage the continuum of care,
program support assures that there is a system-wide program and evaluation infrastructure in
place to coordinate services, build capacity, measure outcomes, assess programs and provide
the necessary training, education and technical assistance to providers and consumers
facilitating consumer access and ensuring high quality of care.
The seventh priority is Planning Council Support. The Commission is required to address
and execute its legislatively mandated priority- and allocation-setting responsibilities and to
ensure that the process of distributing service funding is performed equitably. Further, the
Commission is charged with assessing the administrative mechanism, establishing a system-
wide grievance procedure, evaluating service effectiveness, and educating consumers and the
public on the availability of HIV/AIDS services and opportunities to participate in the
planning process.
The eighth priority is Quality Management. Consistent with the overall mission of OAPP
and the Commission, a QM program provides a systematic way to assess the quality of
services provided to PLWH/A to assure they meet the standards of care adopted by the
Commission. OAPP and the Commission are in the process of establishing standards and a
uniform data collection system.
The ninth priority of the commission is administrative agency support that provides for
operation and overhead of OAPP.

The visual representation of the model accepted by the Commission in 2001 is shown in Figure
1-2. This model lists only Prevention and CARE Act-funded services.

1-5
Figure 1-2 Continuum of Care Model

5. ENHANCEMENT
SERVICE
Psychosocial Support
Service HIV Support
Food Bank, Home DM,
Nutritional supplements
Housing assistance
& services
Transportation
Child care
Client advocacy
Case Management, Psychosocial
Case Management, Medical
Translation/interpretation
HIV Counseling/Testing
Partner Counseling/Referral
Heath Education/Risk Reduction
Medical outpatient
General and Specialty
Treatment Adherence
Nutritional Counseling
HIV/AIDS Medications
Mental health: Psychiatric
Mental health: Psychological
Oral Health
Substance Abuse Services
Hospice Services
Legal Services
Permanency planning
6. PROGRAM SUPPORT
Service Coordination
Capacity Building
Service Enhancement
Evaluation
Training and Education
Program Research/Review
Rate and Fee Review
Program Development
7. PLANNING COUNCIL
SUPPORT
Priority- and Allocation-
Setting
Evaluation Activities
Public Awareness Efforts
Training Activities
Staffing Pattern

Only funded service categories are listed
Prevention Services (not CARE Act-Funded)
1-6
Interface with Comprehensive Prevention Program

Although not funded through CARE Act funds, The Continuum of Care incorporates prevention
in the Primary Health Care Core. As shown in Figure 1-3, the Prevention Planning Committee
(PPC) has developed a comprehensive prevention program. In 2002 the Plan noted, Over the
next two years, the Commission will continue its efforts to integrate the PPC Comprehensive
Prevention Program into the Continuum of Care. Since that time several initiatives have been
started.

With Californias launch of HIV reporting in July, 2003, there is now an enhanced opportunity
for EMAs to develop seamless client services databases that include those testing and being
reported as positive; the Los Angeles County EMA has already begun initiating several of those
efforts. The Commission and the PPC will also join efforts in the development of mutually-
beneficial quality improvement and evaluation tools.

The implementation of HIV/AIDS Interface Technology Systems (HITS) funded by a Part F
Special Projects of National Significance (SPNS) facilitates early entry into care and promotes
better health outcomes. HITS unburdens newly diagnosed individuals from the complexities and
challenges facing clients initially trying to access care. Through a series of three interface
applications to the OAPP data management system, HITS enables HIV Counseling and Testing
(HCT) providers to refer newly diagnosed clients into medical outpatient services, generates
automatic appointment reminders for HCT and clinic staff, tailors referrals to specific needs of
the client, and provides certain pre-screening services.

Planning for HCT services follows a process that categorizes services for specific behavioral risk
groups. The OAPP contracts for these services include compensation for the costs of risk
assessment and follow-up activities for those who fail to return for test results. For those who
test positive, HCT providers are compensated for the costs of linked referrals for services and
partner counseling and referral services. There are more than 450 HCT sites, including 66 fixed
sites and eight (8) mobile units, supported by public funds. HCT services are carefully targeted
to those at highest risk for HIV, which has resulted in increases in the rates of positive test
results. In 2003, the number of tests provided to Latinos increased 2.5% from the previous year,
but the number of new positive results among Latinos increased 20%.

1-7
Figure 1-3 Comprehensive Prevention Program

1-8
PRIORITY AND ALLOCATIONS

Priorities

The Commission has a legislative mandate to prioritize and allocate Title I, selected Title II, and
MAI funds to HIV/AIDS Care services. Since 2002, the Commission has formalized the
planning and allocation function and the steps in that process are shown in Figure 1-4. The
process formalizes the relationship between the subcommittees of the Commission, and further
integrates the activities of the Priorities and Planning, Standards of Care and Finance
subcommittees.

Figure 1-4 Priority and Allocation Process

To facilitate data-based decision making, the Commission staff developed Service Category
Summary Sheets where information from diverse sources is summarized. The information
includes: 1) consumer information from survey and focus groups collected under the HIV/AIDS
Community Assessment Project (H-CAP), 2) utilization data collected through the OAPP client
tracking system (IMACS/Casewatch), and 3) OAPP contract monitoring information. The data
synthesized in the summary sheets is shown in Table 1-1, and selected examples of these sheets
are shown in Attachment 7.
Define framework
Define criteria for
process
Determine process &
service outcomes
Recommend process
for Commission
approval
Oversight Committee
Priorities & Planning
Oversight Committee
Finance
Oversight Committee
Standards of Care
Oversight Committee
Oversight Committee
DIRECTIVE FOR
IMPLEMENTATION
FINANCIAL NEEDS
ASSESSMENT
EFFECTIVENESS
EVALUATION
SERVICE NEEDS
ASSESSMENT
OVERSIGHT AND
MANAGEMENT
Define service
need
Conduct data
collection
Determine unmet
need
Define service
categories
Set and/or rank
priorities

Measure service
efficacy
Determine client
satisfaction
Defines unit cost
Aggregate outcome
data
Perform continuous
quality improvement
Review other
sources of services
funding
Compile service
efficiency and need
data
Make allocations
recommendations to
P&P
Determine
allocations
Recommend How to
Best Meet the Need
Develop Other
Factors to be
Considered
Document process
and submit to OAPP
for implementation
1-9
Table 1-1 Data Elements of Service Category Summary Sheets
! Category, priority and past priority
! CARE Act and other funding
! Service definitions
! Key points of entry
! Units of service and cost effectiveness
! Service utilization: contracted vs. provided
Costs per units and per clients
Variances of contracted vs. provided
! Client demographics
! Utilization analysis
! Expressed need, barriers and gaps
! Issues, trends and impacts

Decisions on priorities and allocations were based on different paradigm and values. Paradigms
represents the ethical perspective from which decisions are made, and values represent the codes
of conduct and values applied to the decision making process. The paradigms and related
choices regarding priorities and allocations are shown in Table 1-2 and values are shown in
Table 1-3.

Table 1-2 Decision Making Paradigms
PARADIGM CHOICES
Caring ethic:

Need and capacity vary
among individuals and, over
time; community must strive
to meet different needs;
community must take
differing capacities into
account; and importance of
complete inclusion.
Absolute Inclusion: no matter how meager the available resources, all community
participants will receive a share of resources; the goal is to sustain complete
participation.
Nuanced Inclusiveness: since there are real differences among participants regarding
needs and abilities, a process for assessing these differences will be developed; this
will allow for differential distribution while assuring complete participation.
Risk Equalization: one way to ensure participation by all is to share risk across all
participants; this maintains traditional allocation while engaging all participants in
efforts to increase resources.
Justice ethic:

People have inherent rights;
there are individual
differences in capacity;
community must strive to
equalize opportunity;
importance of rules of
process; and there are
winners and losers.
Equality: equal portion to each or equal cuts
Equity: relatively equal portions with attention paid to severe need
Fairness: similar cases treated in a similar fashion
Altruism: volunteering to take a cut or go without
Compassion: rescuing those who cannot support themselves/assisting weak and
suffering
Chance: fate decides through random choice; let the universe decide
Coercion: enforced decision by authority
Utilitarianism: greatest good for the greatest number
Rights and Duties: participation in community recognizes reciprocal rights and duties
Retributive Justice: making up for past inequities
Distributive Justice: working towards general equality
Merit: past or current contributions
Market: ability or willingness to pay
Fidelity: recognizing and adhering to past commitments
1-10
Table 1-3 Decision Making Values
VALUE DEFINITION
Efficiency Accomplishing the desired operational outcomes with the least use of
resources.
Survival Maintaining the existence of an organization or system of care.
Quality of Care The highest level of competence in providing care.
Fidelity Multiple commitments that bind and providers to the clients for the duration of
need.
Advocacy The asymmetrical power relationship of provider and client requires the provider
to take care to protect the client.
Beneficence Doing the most good that we are able to do.
Non-malfeasance Avoiding making the situation worse.
Access Ensuring clients access to services in greater numbers or more effective ways;
improving access; increasing access; ensuring 0 disparities.
Representation Implementing decision-making in a way that includes people who adequately
represent and/or reflect the need and diversity of constituencies involved

Because of the uncertainty of funding, the three different funding scenarios noted in Table 1-4
were developed and each scenario was assessed using the paradigms and values.

Table 1-4 Funding Scenarios
FUNDING SCENERIO
1. If the Year 15 Title I award is increased, flat-funded or decreased by less than 4.9%
2. If the Year 15 Title I award is decreased by 5.0 9.9%
3. If the Year 15 Title I award is decreased by 10.0% or more
1

1. Rankings in Scenario #3 were adjusted in accordance with paradigms/values
! Those services providing direct medical care to the greatest number of clients remained the most important.
! Those services ensuring the greatest number of clients access to primary health care became more important.
! Those services affecting the most people or services which could not be accessed elsewhere were considered
higher priority. Services more directly impacting the Continuum of Care were ranked higher.

Using these scenarios, in 2003 and again in 2004 the Commission confirmed their priorities for
the different service groups in the continuum of care, as shown in Table 1-5 and established the
priorities across the different service categories, as shown in Table 1-6.

Table 1-5 Service Category Prioritization
Priority #1: Primary Health Care Core
Priority #2: Removal of Barriers
Priority #3: Patient Care Coordination
Priority #4: Economic Well-Being Measures
Priority #5: Self-Enhancement Services
Priority #6: Program Support
Priority #7: Planning Council Support
Priority #8: Quality Management
Priority #9: Administrative Agency Support
1-11

Table 1-6 Continuum of Care Services by Ranking and Priority

SERVICE CATEGORY
Year 14
Priority
Year 15
Rank
Scenario #1
Year 15
Rank
Scenario #2
Year 15
Rank
Scenario #3
Ambulatory/outpatient, medical,
specialty and nutritional
counseling
1

Treatment adherence
Priority #1/High 1 1 1
Mental health services, psych and
psychiatric
2

Oral health care Priority #1/High 3 3 5
Housing assistance Priority #2/High 4 4 8
Food bank/delivered
meals/supplements
Transportation services
3
Case management, psychosocial Priority #3/High 7 7 3
Case management, medical Priority #3/High 8 8 4
Substance abuse services Priority #1/High 9 9 9
Translation/interpretation Priority #3/High 10 10 12
Legal services Priority #4/Medium 11 11 10
Psychosocial support, HIV
support
Priority #5/Medium 12 16 16
Client advocacy Priority #2/Medium 13 12 14
Child care services Priority #2/Medium 14 13 13
Permanency planning Priority #4/Low 15 14 11
Residential or in-home hospice
care
4

Priority #1/Low 16 15 15
Referral for health care/support
5
Priority #3/Low
1. Medical outpatient, medical specialty, nutritional counseling and treatment adherence were combined into one category
2. Psychological and psychiatric mental health services were consolidated into a single category.
3. As recommended in the OAPP rate studies, van transportation will no longer be funded with Title I/II funds in Transportation.
In accordance with the values, van transportation was accessed by few persons and agencies, it was very expensive per unit
based on cost per client, and there was an inability to track its contribution or outcomes as contributing to the Continuum of
Care.
4. Group home services will no longer be funded with Title I/II funds in Residential. Very few persons accessed the service, and
funding is available through other sources particularly the Department of Family and Children Services.
5. Referral service category was eliminated with the expectation that the administrative agency will be directed toto the extent
that it has not already been doneincorporate referral services into all categories.

Because of the uncertainty of funding for year 16 (FY 2005), four different scenarios for funding
were developed:
7. Any increase.
8. Flat-funded.
9. Decreased by less than 5%
10. Decrease by 5.1% or more.

Irene Hung 1/10/05 16:56
Formatted: Bullets and Numbering
1-12
The P&P committee of the Commission, using the different paradigms and values is in the
process of determining appropriate priorities and allocations.

The Commission, in assessing the priority and allocation for each service draws from several
sources of information, summarized in the Service Category Summary Sheet noted earlier. They
include:
Existing funding information to understand how their allocations of Title I, selected Title II,
and MAI funds fit into overall expenditures categories, including funding by other sources.
Epidemiological data to determine the number of PLWH/A who might demand the services.
Consumer input that documents the perceived need, reported demand and utilization, and the
satisfaction of PLWH/A.

Each of these is discussed in the following sections.

The schedule for the P&P allocation process is shown in Table 1-7.

Table 1-7 Year 16 Allocation Timeline
November 04 December 04 January 05 February 05 March 05
P&P Commi t t e P&P Commi t t ee e
recommends P-
and A-Setting
process to
Executive Executive
Committee Committee
P&P P&P implements
P-and A-Setting
framework
Fi nance Fi nance
Commi t t ee Commi t t ee and
OAPP OAPP collaborate
on Attachment E
(other streams of
funding): forms
finalized and sent
to providers
P&P P&P sends public
notices for
participation in the
process (all
meetings)
P&P P&P selects
paradigms and
operating values
P&P P&P begins
Service Category
Summary Sheets
P&P P&P presents P- and-
A Setting process
report to Commission
Commi ssi oners Commi ssi oners sign
pledges to participate
in process
P&P P&P begins collecting
provider input on
service categories
Consultant Consultant presents
needs assessment
analysis to P&P P&P
Fi nance Fi nance develops
Resource Inventory
SOC Commi t t ee SOC Commi t t ee
assembles information
on unit cost, cost
effectiveness and
service effectiveness
HI V Epi HI V Epi presents
semi-annual Epi report
to Commission Commission
Consultant Consultant
presents needs
assessment to
Commi ssi on Commi ssi on
P&P P&P and OAPP OAPP
finalize Service
Category Summary
Sheets, incorporating
all input
P&P P&P conducts
provider forums
P&P P&P finalizes all
public and provider
input
St af f St af f completes
special population
analyses and P&P P&P
reviews
P&P P&P applies
Change and
Comparability
matrices
P&P P&P sets priorities

P&P P&P presents
Service Category
Summary Sheets and
Priorities to
approves priorities
Fi nance Fi nance analyzes
Attachment Es
Fi nance Fi nance reviews
other sources of
funding
Fi nance Fi nance completes
Resource Inventory
MAI MAI and Program Program
Support Support workgroups
present final
recommendations
Fi nance Fi nance reviews
final PC budget draft
Fi nance Fi nance determines
allocations

Fi nance Fi nance presents
allocations to
Commission
P&P P&P and Fi nance Fi nance
present to directives
to Best Meet the
Need and Other
Factors to be
Considered to
Commission
approves directives
and allocations

1-13
(Year 13 sheets
finalized; Year 14
sheets begun)

FUNDING THE CONTINUUM OF CARE

An Overview of Funding

Table 1-8 indicates that there was over $547 million in funding for care services in 2004 from
Federal, State, and local sources. Figure 1-5 reveals that about 45% of those funds are allocated
to ambulatory outpatient care with another 8% allocated to other outpatient services. Seventeen
percent (17%) of the funds are allocated to ADAP and State funded medication reimbursement.
The Federal government contributes about 58% of the total amount allocated for drug
reimbursement, and the State pays about 42%. About 12% ($66 million) are allocated to support
services, such as case management.

Table 1-8 All 2004 Care Service Funds

CARE Act
Title I
Other
Federal
Funds State Funds Local Funds
TOTAL
FUNDS
Home and Community-Based Support
Services
$8,093,958 $27,460,866 $17,882,067 $12,513,000 $65,949,891
Ambulatory Outpatient Medical Care $16,496,356 $130,488,886 $43,767,660 $55,599,690 $246,352,592
AIDS Drug Assistance Program $54,815,198 $40,515,580 $95,330,778
Other Outpatient Community based Health-
Care Services*
$6,234,005 $14,427,105 $14,261,883 $10,053,933 $44,976,926
Inpatient Medical Care Services $12,794,800 $13,857,614 $15,916,744 $42,569,158
Grantee Administrative Costs, Program
Support, and Planning Council Support
$5,060,260 $17,945,426 $13,714,752 $14,935,603 $51,656,041
TOTAL $35,884,579 $257,932,281 $143,999,556 $109,018,970 $546,835,386
*Includes dental, mental health, nutritional counseling, and substance abuse services.
1-14
Figure 1-5 Distribution of $547 Million in Care Funding

Ryan White Title I, II and MAI CARE Act Funds

The County of Los Angeles received $36,644,121 in Ryan White CARE Act Title I, II, and MAI
funds for 2004. Figure 1-6 displays the distribution of these funds based on the Continuum of
HIV Care and the nine service categories defined by the Commission. Over 60% of the funds
are allocated to the primary health care core, 12% are allocated to patient care coordination, and
9% is allocated to removal of barriers. About 16% is allocated to program and planning council
support, quality control, and grantee administration. As seen in the bar chart to the side of the
pie chart, 5.2% of the funds are allocated to program support, 3.6% to Commission support,
2.1% to quality management, and 5% to Grantee administration. Notable, as seen in Table 1-8
Grantee funds are further supplemented by State and local funds.

Minority AIDS Initiative (MAI)

Minority AIDS Initiative (MAI) funding for 2004 was about $585,000, and it has been used to
reduce disparities and to improve access to services for communities of color, serving African-
Americans, Hispanics/Latinos, Asian/Pacific Islanders, and Native Americans since 2001. The
Commission continued current MAI service allocations, maintained allocation levels for program
support and increased planning council support.5 It also continued MAI funds for outpatient
medical care, oral health, and case management services. In the last two years, MAI services
have been expanded to serve more clients of color, including more women, and in more SPAs.

A majority of MAI funding is allocated to outpatient/medical (47%) and psychosocial case
management (47%) designed to address the needs of clients who may lack access to the care
system due to race and economically-related factors. About 7% of the MAI funds have been
allocated to dental care, funding a mobile dental van to provide additional access to oral health
services in areas previously identified as lacking access.

5
Title I Application for Year 15
Support
Services 12.1
%
ADA
P
17.4
%
8.2
%
Inpatient
Care
7.8
%
Admi
n
9.4
%
Ambulatory Outpatient
45.1
%
Other
Outpatient*
*Includes dental, mental health, nutritional counseling, and substance abuse services.
1-15
Figure 1-6 Distribution of $36.6 million 2004 RWT I, II, MAI Funds

Figure 1-7 displays the distribution of funds within each Continuum of HIV Care category. The
length of the bars reflects the amount of funds distributed to each service in the Continuum of
HIV Care. When assessing the funding allocations, they should be considered in the context of
the overall funding for care services in Los Angeles. For example, some service categories such
as substance abuse or child care may be allocated relatively small amounts because of the
availability of other funding sources.

Although CARE Act Title I, II, and MAI funds assure that the un- and under-insured receive life
preserving care services, several other federal, state, and local programs contribute the majority
of funds to the Continuum of Care. These sources of funding are described in the next section.
2. Removal of Barriers
8.9%
Other
15.9%
9. Grantee Administration
5%
8. Grantee Quality Management
2.1%
3. Patient Care & Coordination 12.1%
4. Economic Well-Being
1.1%
6. Program Support
5.2%
7. Commission Support
3.6%
62
%
5. Self-Enhancement
0%
1. Primary Health Care
Core
1-16
Figure 1-7 Breakdown of Title I & II 2004 Funding

In considering allocations, the P&P committee and Commission considers alternative funding
sources. The Commission has completed a financial needs assessment that suggests several
ways to increase non-CARE Act funding for services in the continuum of care. Due to lack of
data, however, the Financial Needs Assessment was not able to provide an estimate of financial
demand for a service, or a quantitative funding gap for services.

The following sections document available information regarding non Title I, II, and MAI funds
for the continuum of care and incorporate findings from the Financial Needs Assessment where
appropriate.

Non-Commission Allocated Ryan White CARE Act Titles II, III, and Part F Funding

In addition to the Title I, II, and MAI funds under the auspices of the Commission and OAPP,
the CARE Act provides:
The AIDS Drug Assistance Program, ADAP, and the health insurance premium payment
program, CARE/HIPP. Both are funded by Title II funds allocated at the State level. As
shown in Table 1-8, ADAP is the second largest expenditure after outpatient care.
CARE/HIPP is funded at amounts that are modest but sufficient to meet most demand for the
program. Low awareness of the program however may reduce demand.
Early Intervention Grants, Capacity, and Planning Grants directly to providers under Title III.
1-17
Grants to provide services to positive women, infants, children, youth, and their affected
family members under Title IV.
Part F funds directly for dental care, and different special programs through its Special
Projects of National Significance or SPNS projects.

Fourteen Los Angeles providers received or had continued Title III funding in 2003 for a total
estimated $3,933,970. In addition, two Los Angeles providers, USC and the Los Angeles Family
AIDS Network (LAFAN), have been granted $1,685,181 under Title IV. The USC program
provides direct testing and care services to young adults. LAFAN re-distributes Title IV funds to
providers using a RFP process. Those funds are coordinated between OAPP, the Commission,
and LAFAN. Cross title collaboration and planning targets Title IV funds to gaps in services,
and OAPP monitors the contract to avoid duplication in services.

Service Allocations
6

The trend in allocations to the different services is shown in Table 1-9. Between 2002 and 2003
the recommended allocations have remained nearly the same, but in 2004 with a cut of about $6
million there was some adjustments. Outpatient care and dental care were increased slightly, but
most services were cut. Some of the funds for psychosocial case management were allocated for
referrals based on the development of a directory. About $46 million were contracted, and about
$37 million were expended. The service with the largest unspent funds was substance abuse
treatment. Treatment adherence and outpatient psychiatric services also expended significantly
less than contracted. Housing expended about 23% more than they were contracted.

6
OAPP and the Year 15 Ryan White Title I Grant Application are the main sources of the information in this section.
1-18
Table 1-9 Trends in HIV/AIDS Funding
PRIOR-
ITIES
SERVICES
Year 11
Ryan White Title I and
Title II Combined
Priorities
Year 11
Title I, Title II
and County
Estimated
Expenditures
*
Year 12
Ryan White Title I and
Title II Combined
Priorities
Year 12
Title I, Title II
and County
Estimated
Obligations
Variance
Year 12
Priorities
and
Obligations
Year 13
Ryan White Title I
and Title II
Contracted
Year 13Ryan
White Title I
and Title II
Expended
Variance
Year 13
$ % $ $ % $ $ $ % $

Outpatient Medical Services, Medical * 17,641,371 46.5% 20,003,868 17,265,732 42.2% 20,055,007 2,789,275 21,024,765 45.7% 19,571,269 -1,453,496
Outpatient Medical Services, Specialty * 449,584 1.1% 554,624 105,040 544,624 1.2% 437,916 -106,708
Outpatient Medical Services, Psychiatric * 1,103,524 2.7% 1,197,664 94,140 1,179,780 2.6% 932,481 -247,299
Hospice Services **** 326,970 0.8% 391,724 64,754 0.0%

Mental Health Services, Psychological 2,167,796 5.7% 2,191,359 2,329,662 5.7% 2,422,647 92,985 2,422,647 5.3% 2,180,907 -241,740
Nutritional Counseling * 122,614 0.3% 208,063 85,449 208,063 0.5% 190,642 -17,421
Substance Abuse Services 2,317,299 6.1% 2,375,862 2,452,275 6.0% 2,447,794 -4,481 2,389,794 5.2% 1,358,086 -1,031,708
Oral Health Care 448,510 1.2% 501,048 490,455 1.2% 563,919 73,464 696,720 1.5% 653,082 -43,638
HIV/AIDS Treatment Adherence Services 1,526,829 4.0% 1,396,653 1,634,850 4.0% 1,526,829 -108,021 1,664,715 3.6% 1,521,829 -142,886
#1
Patient Education - 0.0% - - 0.0%

Case Management, Medical *** 286,099 0.7% 283,978 -2,121 283,978 0.6% 218,968 -65,010
Referral *** 81,743 0.2% 106,020 24277 0.0%
#2
Other Support Services,
Translation/Interpretation 234,492 0.6% 232,888 245,228 0.6% 244,587 -641 244,587 0.5% 237,188 -7,399

Legal Services ** 380,048 1.0% 388,587 367,841 0.9% 351,202 -16,639 377,497 0.8% 369,481 -8,016
#3
Permanency Planning ** 40,871 0.1% 37,385 -3,486 34,318 0.1% 34,318 0

Case Management, Psychosocial *** 4,036,584 10.6% 3,991,725 3,923,641 9.6% 4,346,681 423,040 4,333,087 9.4% 4,129,011 -204,076
Food Bank/Home Delivered Meals 689,700 1.8% 741,966 735,683 1.8% 721,253 -14,430 760,993 1.7% 751,505 -9,488
Transportation 1,532,407 4.0% 1,948,599 1,634,850 4.0% 2,008,488 373,638 1,784,507 3.9% 1,604,453 -180,054
Other Support Services, Childcare 191,466 0.5% 153,461 204,356 0.5% 197,981 -6,375 205,907 0.4% 175,565 -30,342
Housing Assistance **** 1,980,917 5.2% 6,895,450 1,798,335 4.4% 6,793,720 4,995,385 1,715,896 3.7% 2,104,120 388,224
#4
Client Advocacy 205,907 0.4% 175,565 -30,342

#5 Psychosocial Support Services, Peer Suppt 542,414 1.4% 535,921 572,198 1.4% 557,992 -14,206 557,992 1.2% 486,083 -71,909

SUBTOTALS FOR PRIORITIES 1-5 33,689,833 88.6%

41,357,387 36,066,511 88.2% 45,017,558 8,951,047 46,035,777 88.3% 37,132,469 -3,707,384
* Expenditures are estimates because not verified prior to year end closing

1-19
Medi-Cal and Medicare

Ryan White CARE Act funds and Medi-Cal are the two primary sources f or
reimbursement of HIV/AIDS services, particularly core medical services and case
management services. For those eligible through work history and payment into the
social security system, Medicare refunds health care services. While the exact
contribution of each of these programs is not known, based on the 2004 Need Assessment
of PLWH/A, about 52% of PLWH/A have either Medi-Cal or Medicare (19% have both,
31% have only Medi-Cal, and 2% have only Medicare.) The Financial Needs
Assessment completed in 2003 noted that the average medical care payment for PLWA
is $21,000 per year and 50% of that amount for PLWH. Assuming costs have remained
about the same, the County and its HIV/AIDS service providers could be receiving
between $300 and $400 million in Medi-Cal and Medicare funding. It is estimated that
the country received less that $50 million. As noted in the Financial Needs Assessment,
there is still significant potential for increased Medicaid/ MediCal and Medicare funding
for HIV/AIDS services in Los Angeles County.

Veterans Administration

The VA also provides services under the primary health care core, removal of barriers,
and patient care coordination. The Veterans Administration of Greater Los Angeles
Healthcare System (VAGLAHS) is the largest and most complex in the Department of
Veterans Affairs, spanning four counties (Los Angeles, San Bernardino, Ventura and
Santa Barbara) with two EMAs. VAGLAHS reports currently serving 548 veterans and
dependents of veterans with HIV/AIDS in Los Angeles County. They provide inpatient
and outpatient medical care, housing, substance abuse treatment, pharmacy, and dental
services. Expenditures for these programs are approximately $23 million, including over
$2.2 million in HIV-related drug costs.

The Financial Needs Assessment reports that the VA estimates a cost of $42,000 per HIV
patient per year, and speculates that if 25 PLWH/A were referred successful to the VA
system, it would mean approximately $1 million in additional leverage of CARE Act
resources.

Housing and Urban Development (HUD)

The City of Los Angeles receives approximately $9 million annually from the US
Department of Housing and Urban Development (HUD) in HOPWA funds. CARE Act
Title I and II-funded agencies receive approximately $3.2 million in HOPWA funds
every year. Coordinated through the Los Angeles Housing Department (LAHD),
HOPWA funds are used locally for housing placement, housing assistance, housing
specialists, informational services and housing support services. Section 8 certificates for
PLWH/A are coordinated through LAHD as rental subsidies. Despite HOPWA funds,
the lack of affordable housing in Los Angeles County remains a significant barrier for
clients in the CARE Act-funded system, especially the multiply diagnosed.
1-20

As reported in the Financial Needs Assessment, The Los Angeles Homeless Services
Authority (LAHSA) annually distributes $45-$60 million of McKinney grant funds to
about 80 agencies and more than 120 programs throughout Los Angeles County. The
number of PLWH/A who received these grants is not documented, but they provide
another potential source of housing for PLWH/A.

Los Angeles County Department of Social Services

To supplement Medi-Cal, and related SSDI, The Los Angeles County Department of
Public Social Services (DPSS) runs several general relief programs. CalWORKS gives
cash aid and services to eligible needy California families. Families with limited
resources may be eligible for housing, food, utilities, clothing, or medical care. Families
that apply and qualify for ongoing assistance receive support each month. The Los
Angeles County General Relief Program provides temporary cash aid to individuals who
are ineligible for Federal or State programs. Able-bodied adults can receive aid for no
more than nine months in any twelve-month period. Employment training services are
offered and, if needed, substance abuse treatment is available.

Food Stamps

While food services provided through Ryan White CARE Act funds are a needed
supplement to other County and private programs that provide food, it is not designed to
meet the nutritional needs of PLWH/A. The Los Angeles County Food Stamps Program
was established to improve the nutrition of people in low-income households by
increasing food-buying power. Food stamps are issued in dollar denomination coupons
and are used instead of money at grocery stores.

Substance Abuse and Mental Health Services Administration (SAMHSA)

For FY 2004, the State of California received over $226 million in federal substance
abuse and treatment block grant funding, of which $12.6 million were HIV set-aside
funds. Of these HIV set-aside funds, Los Angeles County received $3,728,911 to support
HIV services for persons in alcohol and drug treatment. These resources support both
Mobile and Drug Expansion (DREX) HIV-antibody testing programs for persons in drug
treatment, as well as residential substance abuse treatment services for persons with
HIV/AIDS. These funds also support HIV education and prevention services for
injection drug users.

The County Alcohol and Drug Program Administration (ADPA) allocates $4.3 million in
NCC funding of contracts with community-based agencies to (a) provide prevention,
treatment and recovery services to County residents and (b) to implement the Countys
Proposition 36 program that helps fund outpatient counseling and residential treatment
program services.

1-21
Child Health Insurance Program

Several agencies provide services to women and children infected with HIV or diagnosed
with AIDS. California enacted the Healthy Families Program in 1997 to implement the
State Child Health Insurance Program (SCHIP). This program provides health coverage
for uninsured children in families with incomes up to 200% of the Federal Poverty Level
(FPL) and who are not eligible for Medi-Cal services, and coverage is similar to that
offered to State employees and includes dental and vision benefits. The use of CARE
Act funds to support primary medical care for children is limited due to the availability of
this funding source.

Department of Children and Family Services (DCFS)

The Department of Family and Children Services (DCSF) has a mandate to provide
and/or refer clients infected with HIV and AIDS to appropriate medical and social
services. They specialize in the placement of children in foster or relatives homes,
provide counseling, and refer children and adolescents for testing.

California Childrens Medical Services

Combined with Title IV funds, medical services supported by non-CARE Act funds for
children and adolescents appear to be sufficient to meet the needs of young people with
HIV/AIDS. The California Childrens Medical Services Branch (CMS) provides a
comprehensive system of health care for children through preventive screening,
diagnostics, treatment, rehabilitation and follow-up services. The HIV Program of CMS
provides funding to screen children at risk for HIV infection and provides infectious
disease and immunology services. Services have been provided to over 10,000 children
since inception of this program. After screening, children with HIV/AIDS are transferred
to the California Childrens Services (CCS) program and linked to comprehensive HIV
treatment and services.

WIC and Child and Adult Care Food Program

Besides medical services, there are several food and nutrition programs for women and
children including the Special Supplemental Food Program for Women, Infants, and
Children (WIC) that provides vouchers for specific nutritious foods along with nutritional
supplements and the Child and Adult Care Food Program that provides meals served to
children in childcare settings. There is also the School Nutrition Program that provides
meals for children attending schools.

Los Angeles Department of Transportation (LADOT), Metropolitan Transit
Authority (MTA), and Access Services, Inc. (ASI)

Persons living with HIV/AIDS frequently identify the lack of transportation as a barrier
in getting medical and other supportive services. The Financial Needs Assessment
1-22
recommends increased collaboration with LADOT, MTA and ASI to obtain
transportation services for persons living with HIV/AIDS in two ways:
Use a portion of CARE Act funds to help PLWH/A purchase Cityride scrip from the
Los Angeles Department of Transportation (LADOT). The Cityride program allows
seniors and persons with disabilities to purchase 72 units of scrip per quarter for
$15.34 ($6.34 for Medi-Cal or SSI recipients). Individuals can use the scrip to
purchase a monthly Metro pass for 12 units, a dial-a-ride for 2-6 units, a private lift
van for up to 8 units, and/or a taxi ride for up to 12 units.
Work with the Metropolitan Transportation Authority (MTA) and its contractor,
Access Services, Inc. (ASI), to provide more curb-to-curb transportation services.
ASI is the federally required ADA paratransit agency that provides both fixed-route
and curb-to-curb services for individuals whose disabilities prevent them from using
regular buses or rail service. OAPP staff should work closely with MTA and ASI to
clarify standards for providing ADA services to PLWH/A.

The Financial Needs Assessment recommends additional ways to increase governmental
reimbursement:

Through the use of Title XIX entitlement funding for Medi-Cal Administrative
Activities. (MAA) and Targeted Case Management (TCM). MAA is open-ended
entitlement funding available to both County departments and contracted agencies
for: (1) outreach, (2) facilitation of the Medi-Cal application process, (3)
transportation of Medi-Cal recipients, (4) program planning to increase capacity and
improve service delivery, (5) program compliance and claims submission, and (6)
training of County and contractor staff on MAA requirements. TCM is designed to
assist a specific group of Medi-Cal recipients with access to necessary medical,
social, educational, and other services through: (1) assessment of client needs, (2)
preparation of individual service plans, (3) service plan implementation and
interagency coordination, (4) assistance in accessing services, (5) crisis assistance
planning, and (6) periodic reviews of case plans. Like Medi-Cal, both involve 50/50
federal and State funding. Utilization of MAA/TCM should be viewed as key to
improving the capacity of HIV/AIDS service providers to become certified to
provider services eligible for Medi-Cal reimbursement.
The Department of Mental Health (DMH) utilizes a certification process and might be
able to certify OAPP-funded mental health service providers if OAPP and the
Commission commit non-CARE Act allocations, such as Net County Costs (NCC), to
the effort. Federal funds cannot be used to match Medi-Cal, because it is already
50% funded through Medicaid. To do so, OAPP would need to support a majority of
its mental health services to PLWH/As with NCC dollars, and the Commission would
need to reallocate CARE Act funds accordingly. Services for indigent clients who are
not eligible for Medi-Cal could still be covered by CARE Act funding.
There is an unknown potential to increased payments from private insurance
providers. 2004 H-CAP data indicates that 8% of PLWA and 9% of PLWH have
private insurance coverage. At an estimated cost of $21,000 per year for PLWA and
1-23
50% of that amount for PLWH, the County and its HIV/AIDS service providers
should be receiving as much as $55.5 million in private insurance payments. It is
likely that the majority of this is recovered because providers are required to bill
private insurance if it is available. However, there may be some unrealized
opportunity to recover reimbursement through insurance by increasing utilization of
the state insurance continuation program.

Recommended 2004 RW TI and TII Allocation

In summary, for Ryan White Title I and Title II funds, the recommended distribution of
funds within the five continuum of care categories is shown in Table 1-10. Following the
service priorities, the primary health care core increased the percentage for 72.2% to
73.6% from year 14 to year 15, while removal of barriers declined from 12.4% to 10.9%.
The third priority (Patient Care Coordination), fourth priority (Economic well-being) and
fifth priority (Enhancement Services) stayed about the same.

Table 1-10 2004-5 Allocations
Service Category Year 14
Allocation
(%)
Year 15
Ranking
Year 15
Allocation (%)
Primary Outpatient Medical Care:
Ambulatory/Outpatient Medical
Ambulatory/Outpatient, Specialty
Nutritional Counseling
Treatment Adherence
52.9% 1 55.3%
Mental Health Services:
Psychological Counseling
Psychiatric Treatment
9.6% 2 9.3%
Oral health care 2.4% 3 2.5%
Residential or in-home hospice care 0.5% 16 Cluster w/ HA
Substance abuse services 6.8% 9 6.5%
Primary Health Care Core 72.2% 73.6%
Housing assistance 5.0% 4 4.7%
Food bank/delivered meals and supplements 2.2% 5 2.1%
Transportation services 4.0% 6 2.9%
Client advocacy 0.6% 13 0.6%
Child care services 0.6% 14 0.6%
Removal of Barriers 12.4% 10.9%
Case management, psychosocial 10.9% 7 11.3%
Case management, medical 0.8% 8 0.7%
Translation/interpretation 0.7% 10 0.7%
Referral for health care/support 0.2%
Patient Care Coordination & Language Care 12.6% 12.7%
Legal services 1.1% 11 1.2%
Permanency planning 0.1% 15 0.1%
Economic Well-being 1.2% 1.3%
Psychosocial support, HIV support 1.6% 12 1.5%
Enhancement Services 1.6% 1.5%
TOTAL*** 100.0% 100.0%

1-24
Figure 1-8 shows the actual expenditures by service category, including the support
categories and quality management.

Figure 1-8 Resource Expenditures for 2004 ($41.8 million)

Primary Health
Care Cor
e
65
%
Removal of
Barriers
12
%
Patient Care
Coordination 11%
Economic Well-Being
1%
Program Support
3%
Commission Support
1%
Quality Management
1%
Administrative Agency Support
5%
Enhancement
1%
1-25
OUTCOMES

To assess the success of a continuum of care, medical and social outcomes must be
measured and tracked. Basic outcomes for the HIV/AIDS continuum of care are
mortality, morbidity, and quality of life.

Mortality: Death Rates and Case-Fatality Rates

Because of the advances made in treating opportunistic diseases and the level of access to
care, AIDS mortality rates have shown dramatic decline over the past decade. However,
the decline in death rates and the death rate at the end of 2003 are not equal among all
racial/ethnic communities.

As shown in Figure 1-9 the death rate (defined by the crude death rate per 100,000)7 has
declined slower among the communities of color, particularly among Latinos. While
from 1994 2000, we noted the much slower decline in death rate among African
Americans, and by 2003, the rate among African Americans remains almost three times
the rate of Anglos or Latinos, from 2000 through 2003, the death rate among African
Americans has declined 40%. This compares to 44% among Anglos and 28% among
Latinos. Nonetheless, with a death rate of 13 per 100,000, African Americans continue to
be disproportionately impacted by AIDS and account for more than 28% of the AIDS
deaths in 2003.

As the population of Latinos in LAC continues to grow, the death rate among Latinos
remains relatively low at about 3 per 100,000. However, this rate represents 158 deaths
in 2003 and 36% of all deaths that year.

7
The mortality rate, or rate of death per 100,000 reflects everyone who was recorded by a doctor on the death certificate as dying of
AIDS-related disease for a specific year. The mortality rate captures trends in current deaths due to AIDS, whether or not they were
ever reported to HARS as a person with AIDS and regardless of when they were diagnosed. Death rates are not shown for APIs and
Native Americans because there were less than 10 deaths reported annually.
1-26
Figure 1-9 HIV/AIDS Deaths by Ethnicity per 100,000 of L.A. EMA Population
Rate (number of PLWH/A)
(
1997 1998 1999 2000 2001 2002 2003
Af Am 26.5(230) 21.0(180) 21.9(185) 18.9(179) 21.7(207) 12.6(121) 13.0(126)
Anglo 12.0(397) 10.0(326) 9.6(308) 7.5(233) 8.5(263) 4.6(142) 4.8(147)
Latino 6.9(287) 5.5(237) 4.6(205) 4.4(188) 4.7(208) 3.8(173) 3.4(158)

The large discrepancy in death rates between African Americans and other ethnic
populations is somewhat moderated by examining the fatality rates shown in Figure 1-10.
This case-fatality rate measures the death rate among the cohort diagnosed with AIDS
during a certain calendar year. While death rates show the disproportionate impact of
AIDS on the African American community, the case fatality rates show the survival rate
once a person is diagnosed with AIDS and accesses the care system. For more recently
diagnosed cases receiving current medication and care, it would be expected that case
fatality rates would decline. Differences in case fatality by ethnic groups could indicate
that African Americans tend to receive services at a later stage of infection or a disparity
in services.

As shown in Figure 1-10, fatality rates have declined drastically among all ethnic groups,
going from about a 29% case-fatality rate in 1997 to less than 9% in 2003. In 2000,
Anglos and Latinos had lower fatality rates than African Americans, but by 2003 the rate
among African Americans dropped below that of Latinos. The small difference in case-
fatality rates among ethnic populations suggests that while African Americans are
disproportionately diagnosed with AIDS and die at a higher rate, once diagnosed with
AIDS and receiving care, African Americans, Latinos, and Anglos are all surviving at
about the same rate.

1-27
Figure 1-10 Case-Fatality Rates

Progression from HIV to AIDS

In addition to declining death rates, early treatment of HIV disease should greatly reduce
the progression of HIV to AIDS. In 1997, 2,179 persons were diagnosed with AIDS in
the Los Angeles EMA, while in 2003, 1,318 persons were diagnosed, representing a
decline of about 40%.

New AIDS Cases by Ethnic Populations

Figure 1-11 shows that while there has been a consistent decline in newly diagnosed cases
from 1997 to 2003, not all ethnic populations have followed the same pattern. For instance,
since 1997 the AIDS rate among Anglos has declined more than 75% while the decline
among communities of color has been smaller, with a decline of 65% among African
Americans, 58% among API, 52% among Latinos, and 41% among Native Americans.
Furthermore, in 2000, the AIDS rate among African Americans (41 per 100,000) was over
four times the rate among Native Americans (9 per 100,000), nearly three times that of
Latinos (14 per 100,000) and Anglos (13 per 100,000), and well over 20 times the rate
among APIs (2 per 100,000).

In terms of absolute numbers needing services, the growing Latino population represents
about 50% of the LAC population in 2003 and represents 43% of the newly diagnosed
cases in 2003. While they are not disproportionately impacted by AIDS, they will
continue to contribute the largest number of HIV cases over the next several years and
their decline in the number of newly diagnosed cases is lower than either Anglos or
1-28
African Americans. African Americans while only about 10% of the total county
population, account for more than 20% of the newly diagnosed cases.

With the growing communities of color in LAC, Anglos now represent about 30% of the
population, and, after Latinos, represent the next largest number of newly diagnosed cases.
They are slightly disproportionately impacted accounting for 32% of the newly diagnosed
AIDS cases.

In planning services for the newly diagnosed, the most units of service have to be allocated
for the Latinos living with HIV and AIDS. At the same time, the system has to prepare for
a rapidly growing number of African Americans living with HIV and AIDS.

Figure 1-11 AIDS Cases by Year of Diagnosis by Race

New AIDS Cases by Risk Group

Figure 1-12 shows an unequal decline in diagnosed AIDS cases for risk groups. MSM
(men having sex with men) show a significant decline in number of AIDS cases
diagnosed yearly from 1997 through 2002, however an upward trend is noted from 2002
to 2003. It will be interesting to observe whether this trend is sustained through 2004.
Nonetheless, in 2001, MSM account for over 56% of the newly diagnosed cases. The
increase shown between 2001 and 2002 in newly diagnosed AIDS cases may reflect a
higher rate of progression to AIDS among MSM that may be due to failed drug therapy
or lack of adherence.
1-29

Since 1997, MSM/IDU have shown the second slowest decline in newly diagnosed AIDS
and have remained at about five percent of new cases. Unlike other large EMAs like
New York, where IDUs play a significant role in new infections, in Los Angeles County
the number of new cases attributable to IDUs has remained relatively low and has in fact
declined by more than 40%. There appears to be a small shift in new infections toward
heterosexuals in the epidemic where, in 2003, the proportion of MSM/IDU and IDUs
among new cases showed a decline from previous years, the proportion of heterosexuals
has surpassed both of those groups and now account for over seven percent of the new
cases.

Figure 1-12 AIDS Cases by Year of Diagnosis by Risk Group

New AIDS cases by SPA

Figure 1-13 displays the decline in AIDS cases reported yearly in the eight SPAs in the
Los Angeles County. Consistently, since 1997, the Metro SPA has accounted for the
largest proportion of all PLWA, with over one third of the cases, followed by SPA 8 the
South Bay-Long Beach SPA with about 18% of the newly diagnosed cases. In the Metro
SPA, 810 AIDS cases were diagnosed in 1997 and 453 in 2003. Next to the Antelope
Valley SPA reporting eleven cases in 2003, the San Gabriel, East and Metro SPAs had
the fastest decline in newly diagnosed AIDS cases.
1-30
Figure 1-13 AIDS Cases by Year of Diagnosis by SPA

Medication and Adherence

Another outcome of the system is adherence to medication. Despite the availability of adherence
programs, PLWH/A report mixed results.

Taking Medication

The use of combination therapy and prophylactics to prevent opportunistic infections has greatly
improved the length and contributed to the quality of life of PLWH/A. Continued and improved
health status outcomes will depend, in part, on the availability, access, and adherence to properly
prescribed medical regimens.

Based on data from the 2004 H-CAP needs assessment survey, both PLWA and PLWH are now
more likely than in 2002 to be taking HIV medications. In 2004, sixty-six percent (66%) of
PLWH and 87% of PLWA are currently taking medicines to treat their HIV infection. As shown
in Figure 1-14, symptomatic PLWA (88%) are more likely to report taking medication than are
1-31
symptomatic (60%) or asymptomatic PLWH (73%). Surprisingly, however, symptomatic
PLWH report a lower use of medication than asymptomatic PLWH.

Figure 1-14 Medication by Stage of Infection

Unlike what was previously reported in the 2002 needs assessment report where men were more
likely than women to be taking HIV medications, in 2004, there is no gender difference in
current use of HIV medications. Over 75% of both men and women are currently taking HIV
medications. This represents an increase in medication use among men and women and may
reflect a greater level of access or more aggressive treatment as the number of people living with
HIV increases.

However, the increased level of access is not shared by all communities. The recently
incarcerated, currently homeless, transgender persons, African Americans, MSM/IDUs and IDUs
report a lower use of medication than any other population. More than half of the Anglo IDU are
currently not taking medications to treat their HIV. This may be due to a number of factors
including the co-morbidity with substance use and or limited access to health care due to their
substance use. These barriers are further explored in the section on these special populations.

Adherence

Among PLWH/A who have been prescribed HIV medication, 41% report never skipping their
medications, and at the other extreme, 8% have stopped taking their medicines. This again
shows an increase in medication use and adherence by PLWH/A in 2004 compared to those in
the 2002 survey, where nearly twice as many (14%) had stopped taking medications.
Figure 1-15 shows adherence to medications across different sub-populations. Data from the
2004 needs assessment reveals that:
Men and women tend to report about the same level (60%) of difficulty adhering to their
medication schedule. However, not shown in the graph is that men are more likely (12%)
than women (9%) to report never have been prescribed medications.
APIs and Latinos are more likely to adhere to their medications than other ethnic population,
while African Americans are the least likely to adhere. Between 10% and 12% of PLWH/A
0
%
20
%
40
%
60
%
80
%
100
%
%

o
f

P
L
W
H
/
A

% taking
antiretrovirals
72.9
%
60.1
%
85.3
%
87.7
%
% taking
antibiotics
10.3
%
20.6
%
43.5
%
49.1
%
PLW
H
asym
p
PLWH
symp
PLW
A
asym
p
PLWA
symp
1-32
of all ethnic groups report never have been prescribed medications. APIs are the least likely
to stop taking medications.
Almost 20% of PLWH have not been prescribed medication for treating their HIV and
among those on medications, 67% report difficulty adhering to their medication.
Notably, undocumented PLWH/A report the highest level of adherence with more than half
of those currently taking medications never skipping a dose.

Figure 1-15 PLWH/A Adherence to Medication

Figure 1-16 and Figure 1-17 show the top 10 reasons for discontinuing medications for all
PLWH/A. The findings indicate that:
Forgetting to take medications, side effects and not wanting to take the medications are the
top reasons for discontinued or inconsistent use of medications.
Among all groups, forgetting to take them (57%) is typically the major reason for skipping
medication, with over 70% of youth and transgenders forgetting to take their medication.
PLWA are more likely to forget to take their medications than are PLWH.
The next two most common reasons cited for skipping doses were side effects of medications
(28%) and not wanting to take medications (22%). Nearly half of the currently homeless and
one third of the Anglo PLWH/A report having problems with side effects.
Five percent of the PLWH/A reported being homeless as one of their reasons for skipping
medications. However, among the currently homeless, less than 15% report their housing
situation as a factor affecting their medication adherence.

0
%
10
%
20
%
30
%
40
%
50
%
60
%
70
%
80
%
%

o
f

P
L
W
H
/
A

Never
Stopped
41.0
%
41.1
%
40.6
%
42.0
%
31.2
%
45.7
%
44.5
%
42.9
%
30.3
%
20.1
%
48.9
%
48.3
%
33.2
%
52.2
%
Have
skipped
51.3
%
51.4
%
50.6
%
49.5
%
60.0
%
47.6
%
54.0
%
50.4
%
59.2
%
68.2
%
42.0
%
45.4
%
57.6
%
39.3
%
Stopped
taking
7.7
%
7.5
%
8.8
%
8.6
%
8.8
%
6.8
%
1.5
%
6.7
%
10.5
%
11.7
%
9.0
%
6.3
%
9.2
%
8.4
%
Tota
l
Mal
e

Female
Angl
o
Africa
n
A
m
Latin
o
API
and
othe
r
MS
M
MSMID
U
ID
U
Heter
o
PLW
A
PLW
H
Undo
c
1-33
Figure 1-16 Reasons for Skipping Medications by Ethnicity

Figure 1-17 Reasons for Skipping Medications by Mode of Transmission

Overall, 12% of PLWH/A report they stopped taking their medications under advice from a
doctor. Women (17%) are more likely than men to cite this reason for skipping medications.
More than 34% of the recently incarcerated also stopped taking their medications under a
doctors advice.

Opportunistic Infections (OIs)

The incidence of OIs, particularly PCP can be used as an outcome for the continuum of care. For
the most part, PCP is preventable provided the PLWH/A remains on their medical regimen and,
should their T-cell count fall below 300, begin a prophylactic of antibiotics. Controlling PCP in
1-34
the epidemic, then requires early detection, adherence, and regular monitoring. As shown in
Table 1-11, when considering the rates of PCP among the general population, the trend for PCP
varies significantly by ethnic groups. While African Americans have shown a dramatic decline
from 1999 through 2003, in 2003, their rate remains more than double that of Anglos and
Latinos. Rates among Latinos and Anglos have fluctuated up and down but have remained
below three per 100,000 over the past seven years.

Table 1-11 PCP by Ethnicity (per 100,000)

However, when examining the PCP rate among the cohort of PLWA, Table 1-12 shows that the
rate is not so dramatically different for the different ethnic groups. While in 1997 the rate for
African Americans was much higher than that of Anglos or Latinos, by the early 2000s the rate
among all ethnic groups begins to look similar. In fact, by 2003, the rate of PCP among Latino
PLWA surpasses that among African Americans. This suggest that once in care, while the rate
remains slightly higher for PLWA of color, all PLWA are similarly likely to develop PCP.

1-35
Table 1-12 PCP by Race among PLWA (per 100 year)

Quality of Life

Other outcomes measured for the system of care are current and changed physical and emotional
health. While no baseline physical or emotional health measures are available for PLWH/A,
survey participants rated their current physical and emotional health and then compared it to
when they first sought treatment for their HIV infection. The assumption tested is that access
to care, and in particular to new HIV drug therapies, have a positive impact on the physical and
mental health of PLWH/A seeking care. Consequently, improved physical or emotional health
after seeking treatment would suggest the care system is meeting one of its major objectives.

Drug therapies, however, may not have the same beneficial affect across all populations, and
some PLWH/A may experience severe side effects that compromise both physical and emotional
health. Additionally, there are disparities in access to care and treatment that may also impact
quality of life. As a result of these factors, it is expected that some of the survey respondents
will report decreasing physical and emotional health regardless of the quality of the treatment.

Figure 1-18 and Figure 1-19 report the current and perceived change in physical health and
emotional health. It is divided into three independent groups: 1) PLWH who are asymptomatic
2) PLWH who are symptomatic, and 3) those who report being diagnosed with AIDS. Of those
living with AIDS, more than 85% said they were symptomatic, with 62% reporting disabling
symptoms.

The majority of asymptomatic PLWH are doing good to excellent and many feel they are
much better than when first diagnosed. Fifty-four percent say that their physical health is
1-36
better now as compared to when they first sought treatment and another 24% say their health
is the same.
In contrast, about 52% of symptomatic PLWH report that their physical health is currently
fair to poor. Nearly one quarter these PLWH say they are doing worse than when first
diagnosed which may be connected to their recent symptoms and possibly the start of HIV
medications that would eventually bring side effects.
While PLWA (14%) are more likely than asymptomatic PLWH (1%) or symptomatic PLWH
(8%) to report poor health, over 75% say they have fair to good health. Overall, PLWA
report comparable improvement in health compared to those at other stages of infection since
they first sought treatment for their HIV infection. In fact, a slightly higher percentage of
PLWA (57%) than asymptomatic PLWH (54%) report improved health.
Overall, the care system appears to be addressing the health needs of PLWH/A and assisting
them in maintaining and in many instances improving their health status. Less than 10% of
the total sample of PLWH/A report poor health. Whether its due to increased medical
monitoring, greater access to social services or heightened awareness about individual health
practices, the majority (56%) of PLWH/A report doing better today compared to when they
first sought treatment.

The emotional health of PLWH/A is better than their physical health.

Among PLWH, the majority (61%) report better emotional health than their initial diagnosis
yet 10% of the asymptomatic PLWH are doing worse than when they first sought treatment.
More than 40% of symptomatic PLWH are doing good to excellent and more than half are
doing better emotionally than when first starting treatment.
PLWA are doing as well emotionally as PLWH. They are feeling better than when first
seeking treatment (58%). This may have to do with success of medication therapy, some
may feel better because they are dealing with drug addictions as noted in the consumer
forums, and others may have consistent medical and social support for the first time in their
lives.
Men tend to report poorer current emotional health than women do. This may reflect the
greater length of time living with HIV but may also reflect a lower level of access to support
systems than women have.
Interestingly, the currently homeless (69%) and the transgender PLWH/A (72%) report the
greatest improvement in their emotional health since they first sought treatment.

Overall, based on improvement in both physical and emotional health, the care system is making
an impact. As a possible indication of the success of aggressive medical intervention, PLWA are
able to manage their infection and report the greatest improvements physically amongst the
different stages of infection. Also, asymptomatic PLWH, whose physical health has remained
relatively constant, have nonetheless benefited from improved emotional and are the population
with the greatest improvements emotionally.
1-37
Figure 1-18 Quality of Life Physical Health

Figure 1-19 Quality of Life Emotional Health

1-38
PROFILE OF THE LOS ANGELES EMA AND THE EPIDEMIOLOGY OF PLWH/A

As expressed in the values of the Commission, another criteria for estimating need is to assure
that services are available, accessible, culturally appropriate, and affordable. That means
understanding the epidemic by various racial and ethnic populations, risk groups, and special
populations. In addition, the Commission has begun the process of more fully understanding the
geographic dynamics of the epidemic to further apportion services equitably throughout Los
Angeles County. In this way disparities among key subgroups and different areas can be closed.

Los Angeles County and the Los Angeles County EMA include the same geographic boundaries.
Population estimates based on the 2000 census reports that Los Angeles County had over 10
million (10,027,533) residents, making it the most populous county in the nation. With 4,000
square miles of land, it has the second largest landmass of all the counties in the U.S. In 2003,
the AIDS rate of 16.6 per 100,000 was above the national rate of 15.2 per 100,000.

When planning for HIV and AIDS services, knowing the number of persons living with HIV and
AIDS, and the number currently accessing services, provides a theoretical referent for the
number of PLWH/A who could seek services in the continuum of care and the number who have
sought services in the past.

Table 1-13 shows that the system currently has about 43,454 PLWH/A who know their status
and thus are in need of some care services. Notably, the number living with HIV is an estimate
as HIV reporting only began in July 2002 in California. The formula for the calculations is
explained in Attachment 8.

Table 1-13 ESTIMATE OF PLWH/A
Living with AIDS in the Los Angeles EMA in June 2004 19,752
1

Estimated Living with HIV (not AIDS) in the Los Angeles EMA through June 2004 (aware) 23,702
Living with HIV/AIDS in Los Angeles EMA in June 2004 who know they are infected 43,454
Estimated living with HIV/AIDS unaware (33% of total aware cases) 14,200
Estimated Total PLWH/A 57,654
Number of PLWH/A who receive care from CARE Act funded providers (unduplicated) 22,403
2

Number of PLWH/A who receive outpatient medical care from CARE Act funded providers 15,731
3

1. From HARS, through June 2004
2. From OAPP client utilization data collection system, through 2003
3. From OAPP client utilization data collection system, through 2003

In theory, the need for CARE Act-funded services is measured by first understanding the current
utilization of services outside of the CARE Act-funded service system, and then calculating the
residual as the number needing CARE Act funded services.

Based on the estimates presented in Table 1-13, 22,403 PLWH/A and collaterals (family
members, children, etc.) are receiving at least one CARE Act-funded service. Consequently,
1-39
21,051 PLWH/A, about 48%, of those who know their status are not seeking care through a
CARE Act-funded provider.

Assuming that the client tracking system is recording most of those receiving CARE Act-funded
services, one challenge is determining how many of the 48% of PLWH/A not accounted for in
the client tracking system need, but are not receiving, CARE Act-funded services and how many
receive these services from other sources. In addition, in allocating funding, the legislative
responsibility of the Commission is to assure that emergency services are used as funds of last
resort. That is, to assure that other available funding is used for services before using the Ryan
White CARE Act funds. Consequently, the task is to estimate how many of those accessing
CARE Act-funded services or in need of services could be accessing other reimbursement
streams such as Medi-Cal, Medicare, federal insurance programs such as CHIP for low-income
mothers and children, or private insurance.

Persons Living With AIDS

In planning HIV/AIDS services, the HIV/AIDS continuum of care will need to provide services
to an increasing number of PLWH/A. While the rate of transmission is dropping, it is more than
offset by the declining mortality rate. The figures on PLWA alone show a dramatic increase
since 1997. The number of PLWA in the Los Angeles County has grown from 14,811 in 1997,
to 19,752 in June 2004. As HIV transmission continues and HIV progression to AIDS continues
to decline, the number of PLWH is likely to have shown an even more dramatic increase.

The Risk Group Profile of PLWA

The AIDS epidemic in Los Angeles County is MSM, and has stayed at about the same
proportion over time. In Figure 1-20, the percentage of MSM living with AIDS has decreased
from 67% in 1997 to 64% in June 2004, but unclassified PLWA has increased and it is assumed
most are likely to be MSM. Generally, MSM represent about two-thirds of PLWA. With over
13,000 MSM (including MSM/IDU) living with AIDS in June 2004, MSM will continue to
comprise the vast majority of PLWA for the foreseeable future. Of all MSM living with AIDS in
June 2004, approximately 45% are Anglo, 34% are Latino, and 17% are African American.
MSM, like others in the epidemic, are increasingly represented by communities of color.

The proportion of heterosexual IDUs has remained constant, representing about seven percent
(7%) of the PLWA. In June 2004, the 1,393 PLWA who are IDUs are slightly more likely to be
African American (37%) than Latino (31%) or Anglo (30%). Given the much lower percentage
of African Americans in the population, they contribute a disproportionate number of IDUs
living with AIDS to the overall epidemic.

The proportion of heterosexuals (non-IDU) living with AIDS has increased from 6.6% in 1997 to
7.4%, or about 1,455 heterosexuals living with AIDS in June 2004. Since 1997, this number
represents nearly a 50% increase from the 980 cases reported in 1997, and is one of the largest
increases in PLWA of any risk group over the past three years. Almost half (49%) of the
1-40
heterosexual PLWA are Latino, 32% are African American, and 16% are Anglo. Almost 70% of
the heterosexuals are women.

Figure 1-20 Living with AIDS by Risk Group

The Gender Profile of PLWA

As shown in Figure 1-21, males continue to represent about 90% of PLWA. However, females
living with AIDS have increased by nearly 40% since 1997, compared to about a 32% increase
among men. In June 2004, women account for the vast majority (68%) of heterosexuals living
with AIDS and about 32% of the IDUs. Since 1997, the proportion of female PLWA has
increased slightly from about 10.2% to 10.7% in June 2004.

1-41
Figure 1-21 PLWA by Gender

The Ethnic Profile of PLWA

According to the most recent population estimates
8
, the racial/ethnic makeup of Los Angeles
County as of 2003 is 46% Latino, 30% Anglo, 13% Asian/Pacific Islanders, 10% African
Americans, and less than 1% American Indian. Figure 1-22 shows, that the HIV/AIDS epidemic
has affected ethnic groups quite differently, and shows the epidemic is continuing to shift from
the Anglo communities to communities of color.

Figure 1-22 shows the increase in PLWA by ethnicity. Since 1997, there is a considerable
increase in Latino living with AIDS and in June 2004, Latinos represent the largest population
(38%) of PLWA, followed closely by Anglos (37%). While Anglos have increased from 6,212
living cases in 1997 to 7,334 cases in June 2004, a 49% percent increase among Latinos living
with AIDS from 1997 to June 2004, means that now a greater number of Latino PLWA (7,502)
than Anglos (7,334) are in need of services in June 2004. African Americans have increased
from 3,250 to 4,245, representing a 31% increase. Together, Asian Pacific Islanders and Native
American/Alaskans (noted in graphic as Other) comprise about three percent (3.1%) of PLWA in
June 2004.

8
Epidemiology Unit in Health Assessment, DHS, LA County
1-42
Figure 1-22 Living with AIDS by Ethnicity

Subpopulations with Small Numbers of PLWA

While there are few PLWA who are Asian Pacific Islanders, Native American or under 24 years
of age, they have special needs, which include the provision of culturally appropriate services.
For young PLWA, particularly adolescent PLWA, providers must take into consideration legal or
emotional issues of minors and those with gay, bisexual and transgender sexual orientation. In
June 2004, there were 510 Asian Pacific Islanders, 99 Native Americans and 276 young adults
living with AIDS.

While the proportion of new cases among young adults has remained at about three percent since
1997, the actual number of persons ages 13-24 living with AIDS has decreased dramatically
since that time, going from 411 persons to 228 persons. Young adults living with AIDS display
a wide range of risk factors. They were most likely to be MSM (28%); however, about 24%
report exposure through transfusion or blood products and an additional 24% report maternal
exposure. The young adults living with AIDS who report maternal exposure suggest the success
of the medical regimen, with pediatric cases surviving into adolescence with AIDS. A large
percentage (16%) remains unclassified.

To obtain a more complete picture of the epidemic and to determine the extent of the need for
early treatment, the next section discusses and compares estimates of HIV along with reported
prevalence of AIDS.

1-43
PLWH/A: Disproportionate Impact

The HIV Epidemiology Program estimated AIDS Incidence in calendar year 2003, and the
number of PLWA and PLWH as of June, 2004. From these estimates, trends in HIV can be
discussed.

Ethnic Racial Distribution of HIV and AIDS

Figure 1-23 shows that the HIV/AIDS epidemic has affected ethnic groups quite differently, and
demonstrates that the epidemic is shifting from the Anglo communities to communities of color.
More than two thirds of the people living with HIV (who have not progressed to AIDS) are from
communities of color. As observed among the PLWA, Latinos (42%) also make up the largest
proportion of PLWH. African Americans account for 24% and APIs combined with Native
American Indians account for an additional three percent of PLWH.

The first set of bars in Figure 1-23 indicates that Latinos represent 46% of LAC residents. While
they represent the highest percentage of PLWH and PLWA, Latinos are not disproportionately
affected. Anglos, the second largest population group in LAC, are disproportionately
represented in AIDS cases, but have far fewer HIV cases. On the other hand, African
Americans, with about 10% of the population, account for 22% of the PLWA and 25% of those
living with HIV, indicating the disproportionate and growing impact of the epidemic on the
African American community. Notably, APIs, the third largest ethnic/racial community with
13% of the LAC population, represent less than 3% of PLWH/A. Native Americans and other
ethnic groups have less than 1% of the populations. However, as indicated in the insert in Figure
1-23, they are disproportionately affected by the epidemic and ways to effectively reach Native
Americans are being explored by the Commission.

Figure 1-23 Impact of HIV/AIDS Epidemic on Racial/Ethnic Communities in LAC

0.0
%
0.2
%
0.4
%
0.6
%
0.8
%
Am
Indian
%

A
m

I
n
d

1-44
Regional Variation

The rate of infection in each SPA varies widely. As shown in Table 1-14, AIDS rates ranges
from a high of 38 per 100,000 in the Metro SPA to 3 per 100,000 in Antelope Valley. What the
table suggests is that the Metro SPA will continue to be the largest epicenter of the Epidemic in
LAC. The South Bay-LB SPA will also continue to be a second, epicenter, and based on trend
data, it will grow as a proportion of all HIV and AIDS cases over time. After the Metro SPA, the
South SPA, with a large proportion of African Americans, has the second highest rate of AIDS
and it will continue to grow as a percentage of HIV and AIDS in LA County.

While rates of infection are useful in comparing areas and projecting increase in service need, in
planning services, numbers of person infected provide a more concrete indication of number of
persons that have to have services. Consequently, Table 1-14 also shows the numbers of persons
in LAC by SPA and the number living with AIDS and HIV. It shows that the Metro SPA had
7,581 PLWA and an estimated 9,097 PLWH in June 2004 that should receive services. At less
than half the number, the South Bay SPA has over 3,368 PLWA and 4,042 PLWH, and San
Fernando has about 2,653 PLWA and 3,184 PLWH in need of services.

Table 1-14 Population and PLWA by SPA
*SPA
Rate of
AIDS Per
100,000 POP % POP PLWA
PLWH
(estimate) % PLWH/A
1 Antelope Valley 3.3 334,366 3.3% 209 251 1.1%
2 San Fernando Valley 8.6 2,102,020 21.0% 2,653 3,184 13.4%
3 San Gabriel Valley 5.2 1,827,448 18.2% 1,371 1,645 6.9%
4 Metro 38.2 1,186,851 11.8% 7,581 9,097 38.4%
5 West 12.2 646,290 6.4% 1,159 1,391 5.9%
6 South 17.5 1,003,993 10.0% 2,058 2,470 10.4%
7 East 5.9 1,350,923 13.5% 1,246 1,495 6.3%
8 South Bay-Long Beach 15.4 1,575,632 15.7% 3,368 4,042 17.1%
TOTAL 13.1 10,027,523 100.0% 19,752 23,702 100.0%

Figure 1-24 displays the regional profile, showing that PLWH/A are much more likely to reside
in the Metro and South Bay-LB SPA than other SPAs. San Fernando, with about 21% of the
population, has about 13% of PLWA, and San Gabriel, with about 18% of the population
accounts for about seven percent of PLWA. On the other hand, the Metro SPA, with less than
12% of the population has nearly 40% of PLWA, and South Bay Harbor has about 16% o the
population and 17% of PLWH/A. Notably the two SPAs with the most heavily represented
communities of color have disproportionately more PLWH/A.

1-45
Figure 1-24 Population and PLWH/A by SPA

The map in Figure 1-25 confirms the unequal distribution of AIDS in LAC. This is updated
from 2002, but the pattern for PLWA has not changed. Notably the zip codes with highest
incidence are located in the Metro SPA, particularly West Hollywood (zip codes 90046, 90069,
and 90028), East Hollywood/Echo Park (zip code 90026) and South Bay Harbor SPA,
particularly in the Long Beach area (zip codes 90802, 90801, and 90832). The map shows the
two epicenters in LAC and shows its spread outward. The West Hollywood epicenter appears to
spread northwest, with the more current spread northward into San Gabriel, along route 170 and
route 5. South, it would appear to follow route 110. The Long Beach Epicenter seems to spread
north, but also appears to be spreading more slowly.

As HIV data becomes more reliable, the regional dynamic of those newly infected is likely to
look different, with the South SPA showing one of the fastest increases in the number of HIV
infections.

1-46
Figure 1-25 AIDS by Zip

1-47
The differences in the impact of HIV and AIDS by SPA is further displayed in Figure 1-26
where the percentage of population (first bar in series), percentage and percentage of PLWH/A
(second bar in series) are compared for each SPA. The diamonds in the graph indicate the
percentage of the population and percentage of PLWH/A for LAC. Thus if the diamonds are
above the bars it indicates that the impact in the SPA is relatively less than the overall impact in
LAC. On the other hand, if the diamonds fall in the bars, the impact in the SPA is relatively
greater than the impact in LAC. Last, in looking at the figures, the pattern of the diamonds and
bars indicate if the pattern in LAC and the pattern of PLWH/A are similar or different.

Highlights include:

SPA 1, Antelope valley has three percent of the total population and is the least populated SPA.
Anglos (48%) make up the largest racial/ethnic group, followed by Latinos (32%) and African
Americans (16%). Anglos represent over 40% of the PLWH/A, but African Americans are
disproportionately represented with over 30% of PLWH/A, compared to 16% of the population
in SPA1. With the declining epidemic among Anglos and the low population, SPA1 will
continue to have few cases of HIV/AIDS with the fastest increase being among African
Americans.

SPA 2, San Fernando, has just about a fifth of the population of LAC, and its racial/ethnic mix is
more likely to represent Anglos (48%) and Latinos (38%) than APIs (10%) or African
Americans (4%). About 50% of HIV and AIDS cases are among Anglos, followed by Latinos
(36%). African Americans are disproportionately impacted accounting for more than 11% of the
PLWH/A in SPA2. Nonetheless, with over 48% of the PLWH/A among Anglos in SPA2, along
with SPA4 and SPA8, SPA2 accounts for the third greatest number of Anglos to the epidemic.

SPA 3, San Gabriel, like SPA 2, has just under a fifth of the population of LAC, but has a
significantly different profile than San Fernando. It has more APIs (25%) than any other SPA,
and HIV and AIDS rates are low. Latinos are the largest ethnic/racial group in SPA3 and
account for the highest number of HIV and AIDS cases. Anglos, tied with APIs as the second
largest population group, have the next highest percentage of HIV and AIDS. However, African
Americans, with just 5%of the population, account for 19% of the PLWH/A cases in San
Gabriel. Given current rates of infection, African Americans could soon overtake Anglos as the
second highest number of PLWH/A.

SPA 4, Metro, has 12% of the overall population and, compared to LAC, has more Latinos and
APIs. It is one of the epicenters in LAC, with about 39% of the HIV and AIDS cases in LAC.
The epidemic in the Metro SPA is fueled by Anglos, who have disproportionate number of HIV
and AIDS cases and Latinos, although the percent of Latinos infected is relatively low compared
to their overall representation in SPA 4. Like other SPAs the relatively small African American
population is disproportionately infected, and APIs account for a small number of the PLWH/A.
MSM represent over 70% of PLWH/A and are, by far, the largest risk group represented in the
Metro SPA.

1-48
SPA 5, West, has about 6% of the population of LAC. Anglos represent almost 65% of the
population, and account for the largest group among PLWH/A (58%). SPA5 has the lowest
percentage of Latinos in LAC. Latinos account for about 16% of the population, yet account for
over 20 % of PLWH/A in SPA5. African Americans, while representing only 7% of the
population in the West SPA, have almost 17% of the PLWH/A. Like the Metro SPA, over 70%
of PLWH/A are MSM.

SPA 6, South, has 10% of the overall population and the epidemic is driven in large part by the
African American population. While African Americans represent 33% of the population, they
represent about 60% of PLWH/A. Over 60% of the population in the South SPA is Latino, yet,
they represent less than 40% of PLWH/A. There are few Anglos living in the South SPA, and
while they are disproportionately infected, they represent under 6% of PLWH/A. MSM
represent the major risk group for PLWH/A, but almost one quarter of the PLWA are
unclassified or of unknown risk.

SPA 7, East, has 13% of the population in LAC. Latinos represent over 70% of the East SPA
residents, followed by Anglos (17%) and APIs (9%). The East SPA is less than 4% African
American. SPA 7 has about 6% of PLWH/A, and Latinos account for over 75% of the
PLWH/A. The Latino community will continue to populate the epidemic in this area. Like other
SPAs, the African American communities are disproportionately infected, but their small
numbers in the East SPA suggest a growing but small impact on the overall number of cases.

SPA 8, South Bay, has 16% of the population of LAC. Along with the Metro SPA, it is an
epicenter in LAC, and its demographics suggest a growing epidemic of PLWA and PLWH.
South Bay has a diverse population, with Latinos representing 37% of the population, Anglos
31%, African Americans 17%, and APIs 15%. Anglos and African Americans are
disproportionately impacted by HIV and AIDS in this SPA, accounting for nearly 70% of the
PLWH/A. At the current pace, it can be expected that African American PLWH/A will continue
to increase yet, Anglos will continue to be the majority of PLWH/A.
1-49
Figure 1-26 Regional Variation - PLWH/A

1-50
CO-MORBIDITIES

The following data for co-morbidities is mostly derived from the 2004 Needs Assessment
Survey and HARS. Detailed demographic and co-morbidity data from the 2002 Need
Assessment. The survey is shown in Attachment 1.

Substance Use

IDU and non-IDU

IDU was never the major mode of transmission for HIV in LAC, and in 2004 it accounts for
about 7% of the PLWH/A with MSM/IDU representing another 6% of PLWH/A. Still,
infected drug users are among the most vulnerable populations as substance use is often
accompanied by other co-morbidities such as homelessness, mental illness, hepatitis and
other STDs, and poverty. While the current rate of infection among IDUs in the LAC is
relatively low, the continuation of needle sharing and an increasing percentage of non-IDU
substance users suggests a highly vulnerable population to infection and re-infection. In
planning for the priority and allocations of Ryan White Care funds to treat HIV and AIDS,
different social and economic indicators can indicate greater need.

The co-morbidity of substance use and HIV includes drugs that are typically injected such as
heroin and crystal meth, but also includes non-injecting substances such as marijuana and
party drugs such as ecstasy and poppers that have been related to unsafe sexual practices
that place individuals at high risk for HIV infection. The survey data of self-reported drug
use indicates that 34% of all PLWH/A report using other, non-injection substances, an
increase from the self-reported 21% from the 2002 Need Assessment. About 25% of
PLWH/A report using crystal meth, a physiological stimulant that can increase sex drive and
almost 60% report using Cialis, Viagra, or Levitra, a sexual potency enhancer sometimes
associated with sex parties. Twenty-five percent also report using poppers, another popular
club drug that can increase sex drive and is associated with momentary loss of control.

Below, IDUs and MSM/IDUs are discussed separately as they may be have different service
needs.

IDUs (Not MSM/IDUs)

IDU (PLWH/A who have injected drugs in the past or self-report their mode of transmission
to be through sharing needles and do not have sex with men) tend to be male (66%) and 64%
are between the ages of 20 and 44, with a third of the IDUs report being 45 years or older.
IDUs tend to be less educated with over half never completing high school or getting a GED
compared to about one third of the overall population of PLWH/A. While less than five
percent of PLWH/A are currently homeless, almost twice as many IDU (9%) are currently
homeless. About 32% of IDUs have been homeless in the last two years, with about 13%
having been homeless for at least 12 months. IDUs (23%) are much more likely to have sent
time in jail than MSM (8%) or heterosexual (13%) PLWH/A However, MSM/IDUs (34%)
1-51
are even more likely to have spent time in jail than IDUs. In addition, IDUs are far more
likely to than any of the other risk groups to have had Hepatitis C (60%) and are also more
likely to have been admitted overnight in a hospital for mental health problems (35%).

MSM/IDUs

MSM/IDU are more likely to be Anglo (43%) and identify as bisexual (29%) than other risk
groups. While more MSM/IDU (77%) have completed high school than IDU (53%), they are
similarly likely to be employed (18%) and to report less than an $18,000 annual income
(92%). MSM/IDUs (34%) are more likely than IDUs (23%) to have spent time in a jail or
correctional facility in the last two years. Like most other PLWH/A, MSM/IDU are likely to
live in a rented apartment (67%), however, they are more likely to reside in a drug treatment
facility (12%) or assisted living situation (8%) than other PLWH/A. MSM/IDU are more
likely than PLWH/A of other risk groups to have sexually transmitted illnesses. Eighteen
percent (18%) report having had syphilis in the past two years, 18% gonorrhea, and 15%
report genital warts. They are the group most likely to receive mental health services, with
88% having received mental health counseling since being diagnosed with HIV, 90%
receiving individual counseling 74% taking medications for behavioral or psychological
problems. A significantly higher percentage than other risk groups, has been diagnosed with
anxiety (55%) and depression (67%).

Poverty

Persons living in poverty often cannot afford basic needs such as food and housing, health
care or insurance that would pay for health care, or, if they have insurance, the co-pays that
often accompany claims. Poverty is related to unemployment, homelessness and substance
use, and these, in turn are related to HIV.

According to the 2004 poverty guidelines, the poverty level for a one-person households is
$9,310 and 300% of federal poverty level (FPL) is $27,930. For three person households
100% of the poverty level is $15,670 and 300% FPL is $47,010 (See Attachment 9)

Notably, PLWH/A are more likely than the general population to live in poverty, with more
than 60% of the participants in the 2004 needs assessment survey reporting incomes below
the poverty level. Not surprisingly, over 96% of the PLWH/A in the 2004 needs assessment
report incomes below the 300% FPL, the usual cutoff for receiving CARE Act funded
services. As shown in Figure 1-27 women are more likely than men to live in poverty.
Among the risk groups, almost 80% of heterosexuals report living in poverty. Also,
PLWH/A from communities of color are much more likely than Anglos to live in poverty,
with more than three quarters of Latinos reporting annual incomes below the poverty level.
Recently incarcerated, undocumented and women of child-bearing age are among the top
groups most likely to live in poverty.
1-52
Figure 1-27 PLWH/A Living Below Poverty Level

Insurance

Table 1-15 shows the insurance status of the population in LAC and each of the SPAs. It
also shows the percentage of PLWH/A with different types of insurance.

Over 30% of the adults in LAC do not have insurance, and 20% of the children are
uninsured. LAC has a higher rate of adults uninsured than the entire state of California. The
highest rates of uninsured adults are in the South (36%) and Metro SPA (38%), followed by
the East SPA (29%). These are the three areas with the highest prevalence of HIV and
AIDS, and both have large Latino communities, which are much more likely to not have
insurance than other racial and ethnic communities. As shown in Table 1-15, 49% of Latinos
are uninsured, compared to 25% of APIs, 19% of African Americans, 18% of Anglos, and
16% of Native Americans.

Based on 2004 H-CAP Questionnaire (see Table 1-15) about 36% PLWH/A report being
uninsured. Those PLWH/A who are insured, however, are much more likely to report Medi-
Cal or Medicaid (50%) and Medicare (22%), than private insurance (10%). Those in the
OAPP Client Database are even more likely to be uninsured (51%) reflecting the greater
reliance on Ryan White Title funded programs by uninsured PLWH/A.

According to the H-CAP data, Latinos (54%) are much more likely to be uninsured than
either Anglos, African Americans, or APIs. This is directly correlated to the 81% of
undocumented PLWH/A who report being uninsured. Not surprisingly, PLWH (48%) are
less likely to have insurance than PLWA (22%). Special populations that have a lower rate
of insurance include youth (45%), recently incarcerated (49%), transgenders (54%), and
undocumented (82%).
1-53
Table 1-15 Insurance by Ethnicity and SPA

% adults with no
health insurance
% children
w/o health
insurance
% Medi-
Cal
%
Medicare % Private
Gen Pop California 22.2* 19.0*
Los Angeles County 31.4* 20.3* 8.6* 0.6* 59.3*
Race Latino 48.9* 9.3* 0.2* 41.5*
Anglo 18.1* 4.9* 1.0* 75.9*
API 25.2* 8.6* - 66.0*
African American 18.8* 18.6* 1.6* 61.0*
Native Americans 16.4* 24.4* - 56.5*
SPAs Antelope Valley 17.6 8.3 13.7* 1.8* 63.7*
San Fernando 24.5 8.3 5.8* 0.4* 66.1*
San Gabriel 22.3 7.2 8.2* -* 62.8*
Metro 37.6 14.3 9.9* 0.8 45.8*
West 16.0 6.7 6.1* -* 70.8*
South 36.4 17.7 14.7* 0.9* 37.0*
East 28.7 10.2 8.0* 0.6* 58.3*
South Bay 22.5 9.6 9.1* 1.1* 63.2*
PLWH/A PLWH/A (2004 Survey) 35.5 NA 50.1 21.5 10.2
PLWH/A (OAPP clients) 54.9 NA 18.7* 3.3* 6.7*
*Data based on 2002

STDs

Since the beginning of the AIDS epidemic, researchers consistently have suggested an
association between HIV/AIDS and other STDs. Numerous national studies have indicated
at least a twofold to fivefold increased risk for HIV infection among persons who have other
STDs.

Syphilis

While in the late 90s the number of early latent syphilis cases declined dramatically, by 2000,
primary and secondary as well as early latent syphilis began on an alarming upward trend.
As shown in Figure 1-28, from 2000 to 2003, primary and secondary increased by almost
70%, going from 136 in 2000 to 442 in 2003. Similarly, early latent cases increased from
200 in 2000 to 365 in 2003.
1-54
Figure 1-28 Syphilis Cases (1998 -2003)

Seven percent (7%) of the PLWH/A in the 2004 H-CAP report having had syphilis in the
past year. Syphilis tends to be more prevalent in PLWH/A who are Latino (11%),
MSM/IDU (18%), recently incarcerated PLWH/A of color (17%), undocumented (15%), and
transgender individuals (30%). These populations are mostly male, have more sexual
partners than other populations. The rate among Latinos may also be partially explained by
their lack of access to regular medical care.

Gonorrhea

Like primary and secondary syphilis, gonorrhea rates have climbed since 1998. As shown in
Figure 1-29, the rate of gonorrhea has increased by 25% from 1998 to 2003, going from
5,986 cases to over 8,000.

Figure 1-29 Gonorrhea Cases (1998 - 2003)

1-55

PLWH/A in H-CAP report a much higher rate of gonorrhea (8%) compared to the rate
reported by PLWH/A in 2002 Needs Assessment (2.4%). Gonorrhea occurs more in men
(9%), Anglos (11%), the currently homeless (18%), and MSM/IDU (18%). The currently
homeless population and MSM/IDU also have higher rates than other populations of not
having seen a doctor for more than twelve months (28% and 42%, respectively). This may
suggest a more aggressive and successful treatment of gonorrhea among other PLWH/A who
attend regular medical appointments.

Hepatitis

Hepatitis C

The California Department of Health Services estimates there are approximately 200,000
people (2% of the population) with hepatitis C living in Los Angeles County with an
incidence rate in 2002 of .26 per 100,000 population. In 2002, there were 9,691 case reports
of HCV infectionincluding acute, chronic, and resolved casesa 15% decrease from 2001.
Of those cases, only two could be confirmed as acute infections.

The highest risk for the virus is through nasal ingestion of cocaine, intravenous drug use,
using shared infected needles in unlicensed tattooingas occurs in prisonand unsterilized
tools in body piercing. Findings from the 2004 H-CAP data reveal that about 15% of
PLWH/A have had hepatitis C in the last 2 years. Among IDU this rate is 60% and among
MSM/IDUs it is 35%. It is also very high among homeless populations (25%), recently
incarcerated (35%), and transgenders living with HIV and AIDS (37%). These populations
have a high co-morbidity of substance abuse.

Hepatitis A and B
9

Hepatitis A rates have fluctuated since 1993, ranging from about 10 per 100,000 in 1998 to a
high of about 16 per 100,000 in 1997. The 1997 hepatitis A crude rate (16.4 per 100,000
population) in 1997 represented a 10% over the 1996 rate of 14.9 per 100,000.

By 2000, the rate of HAV dropped to about nine per 100,000. Within SPAs, SPAs 4, 6, and
7 have the highest rates (9.9, 9.8,and 8.8 per 100,000, respectively), while SPAs 3, 5, and 8
have rates significantly lower than the county average.

From 1992 to 1993 there was steep decline in the incidence of Hepatitis B in the LAC. Since
then the rate has leveled off and ranged from about one to five cases per 100,000. In 2000,
there were 65 cases of HAB reported, with an incidence rate of less than one case per
100,000.

According to the H-CAP data, 14% of PLWH/A report having Hepatitis A or B in the last
two years. It occurs more often in males (15%) and MSM/IDU (22%). African Americans

9
Text for rates unchanged from 2002 Needs Assessment
1-56
and Anglos are equally likely to have had Hepatitis A or B in the past year. Populations with
higher occurrences of Hepatitis A or B include youth (37%), PLWA (21%), recently
incarcerated (19%) and currently homeless PLWH/A (19%)

Tuberculosis

Based on County of LA Health Department Data shown in Figure 1-30, since 1998, the
overall rate of tuberculosis in LAC has steadily decreased. However, not all ethnic
populations have had the same level of decrease, and with high number of immigrants
moving to LA from high incidence areas overseas, there is a need to carefully monitor the TB
rate. In 2003, Latinos account for nearly half (46%) of the tuberculosis cases, followed by
APIs (36%). However, APIs with a rate of 27.7 per 100,000 and African Americans with a
rate of 10.3 per 100,000 are the communities most impacted by tuberculosis.

Figure 1-30 Trends in Tuberculosis by Ethnicity

According to the Los Angeles County Department of Health Services, TB Control Program,
in 2003, about eight percent of the individuals with tuberculosis are co-infected with HIV,
36% of the co-infected are substance users, and 23% are homeless. Among the HIV co-
infected TB cases, 65.3% were Latino, 16% African American, 12% Anglo, and about 7%
were API.

Homelessness

Stable housing is often a prerequisite for a PLWH/A who are trying to adhere to a difficult
medical regimen and improve their quality of life. Living in shelters and inconsistent access
to food and proper nutrition further aggravates the difficulty adhering to medications. In
many cases, HIV/AIDS is both a cause and a result of homelessness. It is believed that HIV
infection in homeless communities varies from 3 percent to 19.5 percent with a significantly
1-57
higher rate of infection in subgroups such as communities of color, intravenous drug users,
women, and youth. Overall, the County of LA HIV Epidemiological Department estimates
that 3.5% of those with unstable housing or who are currently homeless are infected with
HIV.

The Housing Opportunities for Persons with AIDS (HOPWA) program, enacted as part of
the National Affordable Housing Act in 1990, distributes funds based on a federal formula to
jurisdictions with the largest number of reported AIDS cases. In Los Angeles received
approximately $9,700,000 in HOPWA funds, of which $3.2 million are distributed through
CARE Act Title I and II funded agencies. HOPWA funds can be used for various housing
activities, including capital, supportive services, rental assistance, and technical assistance.
Capital activities include acquisition, rehabilitation, conversion, new construction, or leasing.

The City of Los Angeles Housing Department (LAHD), the HOPWA grantee for LAC, has
created seven HOPWA program categories with the goal of devising long-term
comprehensive strategies for meeting the housing needs of low-income PLWH/A and their
families in LAC. The program categories include 1) centralized countywide housing
information services clearinghouse, 2) emergency housing and meal vouchers, 3) short-term
rent, mortgage and utility assistance, 4) housing specialists to assist PLWH/A in locating and
maintaining appropriate housing ,5) lease operating and supportive service costs in
emergency shelter and transitional housing, 6) supportive services in permanent housing and,
7) scattered site master leasing.

While a small percentage of PLWH/A are currently homeless, according to state estimates,
one-third to one-half of people living with HIV/AIDS are either homeless or at risk of
becoming homeless. An alarming 50 percent of individuals with HIV/AIDS are expected to
need housing assistance during the course of their illness. And it has been reported that few
homeless individuals know their HIV status and even fewer are informed about treatment
options.

According to the State of California 1999 Statewide Housing Plan, prepared by the
Department of Housing and Community Development (HCD), annual estimates for Los
Angeles County indicate that in the course of one year, there are approximately 236,000
homeless people in the County and up to 84,000 persons are homeless on any given night.
Estimates are that up to 50% of homeless adults have severe mental disorders such as
schizophrenia, depression and/or bipolar affective disorder. Forty percent (40%) are addicted
to both alcohol and drugs and up to 80% of homeless adults have a concurrent disorder such
as alcohol or drug addiction.

In addition, the study conducted by Los Angeles County Department of Health Services
found that the greatest number of homeless cases (38%, 29 cases), were located in the Metro
SPA, a region characterized by high population density, severe poverty and a large number of
persons with other risk factors for TB such as HIV infection, injection and non-injection drug
use and severe alcohol abuse. The OAPP Client Database data confirms the studys findings
and shows that over one third (36%) of the homeless PLWH/A live in the Metro SPA. The
1-58
OAPP Client Database shows that the South Bay SPA has the second largest concentration of
homeless PLWH/A, accounting for about 22% of the homeless PLWH/A in the LAC. 77%
of the currently homeless population lives in SPA 4 according to the results of H-CAP 2004.

Of the 732 H-CAP participants as of November 2004, fourteen percent (14%) are currently in
an unstable housing situation, either homeless or in some form of transitional housing.
Moreover, 35% report history of homelessness or transitional housing in the past two years.
Twenty percent (20%) of the PLWH/A with a history of homelessness feel that their housing
is unsafe and 30% feel that their current housing is unstable. Among the PLWH/A with a
history of transitional housing, 16% feel that their current housing is unsafe and 15% feel it is
unstable.

Figure 1-31 shows that women are slightly more likely than men to be currently in an
unstable housing situation. Not surprisingly, IDUs are more likely to be homelessness in
part due to the nature of the sampling and in part because drug use is highly related to
homelessness. African American and MSM/IDU are more likely to be in transitional
housing.

Figure 1-31 Homelessness & Transitional Housing by Race, Gender and Risk Group

Not surprisingly, the large majority (83%) of the currently homeless live in poverty and more
than one third has less than a high school education. They are likely to be symptomatic
(86%), have lived with HIV for more than three years (83%), and report a higher prevalence
of Hepatitis C (32.3%) than other populations. As expected, less currently homeless
PLWH/A are taking medication and are more likely to experience difficulty adhering to the
regimen, with nine percent skipping medications more than twice a week, and 12%
discontinuing their medication. Twenty-eight percent report a period of 12 months without
seeing a doctor and return to medical care because they got sicker or there was a change in
income. Fifty-nine percent (59%) cited other reasons for returning to care, including drug
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1-59
abuse, someone bringing them to the hospital, moving to the US, needing a HIV-diagnosis to
get housing, and their own desire to find out. Currently homeless PLWH/A, are much more
likely than other populations report having bipolar disorder (30%) or dementia (24%).

The instability of housing becomes more evident when PLWH/A are asked if they have been
homeless or in transitional housing in the last two years. Of the PLWH/A interviewed, over
21% report having a history of homelessness and 25% report having lived in transitional
housing. The data reveals that:
Women have consistently been more likely to be homeless or in transition than men.
About 36% of women have a history of unstable housing compared to 34% of men.
Participants with a history of unstable housing are much more likely to be MSM/IDU
(56%), IDU (54%), or African American (45%).
Not surprisingly, recently incarcerated PLWH/A report the greatest level of housing
instability. Eighty percent (80%) of the recently incarcerated PLWH/A have been
homeless or in transitional housing during the past two years. This may reflect the
financial challenges and rules and regulations of public housing one faces after being
released from the jail system.
Nearly 40% of women of children-bearing age report a history of unstable housing.

1-60
NEEDS, UNMET NEEDS, GAPS, AND SERVICES DELIVERY BARRIERS

Service Categorization

The 2002 Needs Assessment survey was responded to by 246 PLWH/A, and the 2004
Needs Assessment survey was responded to by 732 PLWH/A. The 2004 sample
purposefully over-represented women, African Americans, and IDUS. These over-
sampled subpopulations were weighted back to their estimated proportion in the
populations of PLWH/A in order to provide a more accurate analysis of all PLWH/A.

In 2004, participants were asked to rank their awareness of need, demand, utilization, and
satisfaction for 44 services (see Q. 36 in the 2004 Needs Assessment Survey). As shown
in Table 1-16 on the following page, 27 services are partially or fully funded by the Ryan
White CARE Act, and prioritized by the Commission. Seventeen (17) are important
services in the continuum of care, but receive no Ryan White CARE Act Title I funding.
They are funded by other channels including Title II, III, and IV of the CARE Act,
HOPWA, State funding, Medi-CAL, VA, DMH, NCC, SAMHSA, WIC and other
sources. In Table 1-16 these services are presented by the five priority categories in the
LAC Continuum of HIV Care, and the number in brackets is the Year 15 priority ranking
of services by the Commission. Where possible, utilization figures are compared to
utilization reported in the Information Management of AIDS Clients and Services
(IMACS)/Casewatch and Toolbox client tracking system used by OAPP. According to
these databases there are 22,403 unduplicated clients, including HIV-negative collaterals
and pediatric AIDS cases using the CARE system in 2003.

Most Needed Services

PLWH/A were asked if they needed the service in the past year for each of 27 Ryan
White CARE Act funded service categories and 17 additional non-CARE Act funded
services shown in Table 1-16. A similar question was asked in the 2002 needs
assessment and trends are noted. However, due to the more rigorous methodology and
larger sample size of the 2004 survey, only large difference and trends should be
considered reliable.
10
.

10
The 246 respondents in the 2002 Needs Assessment survey were interviewed at community focus forums and were largely self-
selected. The 732 respondents in the 2004 Needs Assessment were selected using a stratified quota sample and while limitations are
noted in the methodology section of this report, the findings are reliable.
1-61

Table 1-16 Needs Assessment Survey Services (2004)

1. PRIMARY HEALTH CARE CORE
Outpatient medical care [1]
1

Medical care by a specialist [1]
Nutrition education and counseling [1]
Individual mental health services (out) [2]
Group mental health services (out) [2]
Family Counseling [2]
Residential mental health [2]
Dental care [3]
Outpatient substance abuse services [9]
Residential substance abuse services [9]
Detox and/or methadone maintenance [9]
Drug reimbursements [NR]
Treatment Adherence [NR}
Home health care [NR]
Hospice services (in-home and residential)
[NR]
HIV Prevention at a doctors office [NR}
Health education/Risk Reduction [NR]

2. REMOVAL OF BARRIERS
Residential housing or group home [4]
Housing information [4]
Emergency or transitional housing [4]
Food pantry or food bank [5]
Home-delivered meals [5]
Taxi vouchers or bus tokens [6]
Bus tokens [6]
Bus passes [6]
Client advocacy [13]
Health insurance continuation [13]
Day care for children [14]
Food vouchers [NR]
Nutritional supplements [NR]
Rental subsidies [NR]
Independent housing (e.g. through Section
8 or HOPWA) [NF]
Van transportation [NF]
Emergency financial assistance/ rent & util
[NR]
Emergency financial assistance / not rnt&
util [NR]
Adult day care [NR]

3. PATIENT CARE COORDINATION
Psychosocial case management [7]
Medical case management [8]
Translation/interpretation services [10]
Referral / Directory [NR]

4. ECONOMIC WELL-BEING
Legal services

5. ENHANCEMENT SERVICE OPTIONS
Peer counseling [12]
Employment Assistance [NR}
Buddy services [NR]
Spiritual Counseling [NR]

1. The number in brackets is the year 15 priority.

Top Rated Needs

The percentage of the PLWH/A sample needing the service in the past year is shown in
Figure 1-32. Within each of the five priority categories in the continuum of care, the
services are ranked by reported need of PLWH/A. The numbers above the bars shows
the ranking of need by participants, regardless of the category of the service in the
continuum of care.

Figure 1-32 indicates that:
1-62
The most needed service in 2004 is outpatient medical care, the same as in 2002. In
2004 about 95% of PLWH/A said they needed outpatient medical care in the past
year.
The second and third most needed service in 2004 is dental care and psychosocial
case management both (77%). Dental care remains the second rank need followed by
psychosocial case management which is up from fourth in 2002.
Bus passes were the fourth ranked service in 2004. In 2002 bus passes were not
ranked, but taxi vouchers were ranked as the fifth most important service. Notably
when more transportation options were presented to the consumer in 2004, taxi
vouchers were ranked significantly lower, while bus passes were among the top five
most needed services.
Food pantry, part of the removal of barriers cluster, ranked fifth, with 69% of
PLWH/A saying they needed the service in the past year.
Nutrition education stayed in the top ten most needed services in 2004 with just under
64% reporting a need for nutrition services in the past year.
There was a greater reported need for medication reimbursement in 2004 than 2002.
In 2004, 63% of PLWH/A said they needed medical reimbursement in the last year
and it was ranked as the 8
th
most needed service. In 2002 53% said they needed it in
the past year and it was ranked 11
th
.
Within the primary health care core, over 50% of the participants also said they
needed individual mental health counseling, visits to medical specialists, and
prevention information from the primary care giver.
In addition to the 4th ranked need for bus passes and 5
th
ranked need for food pantry,
other services needed by over 50% of the participants in the removal of barriers
cluster were independent housing and food vouchers.
Consumers reported a greater need for psychosocial case management than medical
case management. Still, over 56% of the participants reported needing medical case
management in the last year.
None of the services in the economic well being cluster or the enhancement
service were rated among the top twelve needs of the participants. There appeared
to be a significant decrease in perceived need for peer counseling in 2004 (44%)
compared to 2002 (54%), although this may be attributable to the different sampling
strategies used in the needs assessments.
Substance abuse services were reportedly needed the least by the participants. Given
the relatively low percentage of IDUs in the population of PLWH/A (14%, including
MSM/IDUs), this is not surprising. However, as seen in the later subgroup analysis,
even among drug users, the relative demand for substance abuse programs is low.

1-63
Figure 1-32 Ranked Service Needs

Primary Health Care
Core
0
%
20
%
40
%
60
%
80
%
100
%
%

P
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W
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PLWH/
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95.1
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77.6
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63.9
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63.2
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58.7
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57.9
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54.5
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39.3
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35.7
%
35.3
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23.3
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18.2
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17.6
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1-64
Top Service Needs: Gender Differences

As shown in Table 1-17, the top five needs of men and women are about the same. Both groups
rank outpatient medical care, dental care, and psychosocial case management, bus passes, and
food pantry among their top five most needed services. Women were much more likely to report
needing medical specialists than men. None include food pantry services in their top three
ranked service categories, while both included dental services. Women rank medical case
management as a low priority (17
th
) while men rank it 11
th
.

Table 1-17 Top Ranked Service Needs by Gender
Service Needed in the Past Year Rankings (1=top ranked 44=lower rank)
All PLWH/A Male Female
Outpatient med care 1 1 1
Dental 2 2 3
Psychosocial case management 3 3 2
Bus pass 4 4 5
Food pantry 5 5 4
Nutritional education 6 6 11
Independent housing 7 8 7
Med reimbursement 8 7 10
Food Voucher 9 9 8
Individual mental health counseling 10 10 9
Med specialist 11 12 6
Medical case management 12 11 17
Prevention information at doctors office 13 13 12
Nutritional supplements 14 14 24
Referrals 15 15 19

The top six needs for women living with HIV and AIDS are outpatient medical care (97%),
psychosocial case management (82%), dental (77%), food pantry (74%), bus passes (73%), and
medical specialists (72%). For men, the top six are outpatient medical care (95%), dental (78%),
psychosocial case management (76%), bus passes (73%), and food pantry (68%), and nutritional
education (64%). The largest difference from 2002 is a decreased perceived need for taxi
vouchers for women.

The service needs with the largest differences between males and females are shown in Figure
1-33. This figure indicates that:

Women are significantly more likely to report needing taxi vouchers and medical specialists than
men. In the primary medical care core, they are also more likely to report needing mental health
services, including family counseling and individual mental health counseling, and prevention
services.

Women have a greater need than men do for services that remove barriers to care, including taxi
vouchers, child care, rental assistance, and emergency financial assistance. Women also report a
greater need for enhancement services, such as peer counseling and buddy support, as well as
legal services in the economic well-being cluster.
1-65

Men are less likely to have greater needs than women. Perhaps reflecting their greater substance
use, they are somewhat more likely than women to need residential mental health. They also
express a somewhat higher need for nutritional supplements.

Figure 1-33 Need - Difference by Gender

Top Service Needs: Ethnic/Racial Differences

Table 1-18 compares the top fifteen service need rankings between all PLWH/A, Anglo, African
American, Latino, and API and other individuals living with HIV and AIDS. There are
considerable differences in the rankings and percentage of each ethnic population reporting a
need for each HIV/AIDS care service in the next year.

Anglos rank nutritional education, individual mental health, medical specialists, and nutritional
supplements considerably higher than other ethnic communities do. They are significantly more
likely to say that they need medical specialists (65%) and somewhat more likely to say they need
medical specialists (67%). Anglos are less likely to say they need transportation services,
prevention services in a doctors office, and medical case management.

African Americans tend to rank the need for food vouchers, bus passes, medical case
management high then the general population. As shown in Figure 1-34, African Americans,
when compared to all PLWH/A, have a significantly greater need for bus tokens and bus passes,
housing information and transitional housing. They report a somewhat higher need for
prevention education and medical case management. The have a significantly lower need for
referrals from a directory, legal services, and medical specialists.

1-66
Latinos tend to rank medication reimbursement and prevention at a doctors office higher than
other ethnic populations. Figure 1-35, indicates that Latinos have a significantly greater need
than all PLWH/A for translation services, prevention information at their doctors office, and
health information from a health educator, and family counseling. They do not have
significantly lower need than all PLWH/A for any service.

Given that there are only 27 API and other ethnicities in the sample, the findings reported below
may not be reliable. Given this caveat, the 27 APIs and PLWH/A from other ethnicities report a
higher need than other PLWH/A for food -- both food pantry and food vouchers. At the same
time they say they have a much lower need for nutritional education. In Figure 1-36, API and
other ethnicities report a greater need for residential mental health, bus tokens, food pantry, and
buddy support than all PLWH/A. Figure 1-36 also shows that, in general API and other
ethnicities have a lower reported need for group mental health, medical specialists, workforce
reentry, and nutritional education services than other PLWH/A.

Table 1-18 Service Need Rankings by Ethnicity
Service Needs in the Past Year Rankings (1=top ranked 44=lower rank)

All PLWH/A Anglo Af Am Latino
API &
Other
Outpatient med care 1 1 1 1 1
Dental 2 2 6 2 2
Psychosocial case management 3 3 3 4 5
Bus pass 4 10 2 3 4
Food pantry 5 6 4 8 3
Nutritional education 6 4 10 9 25
Independent housing 7 11 7 6 6
Med reimbursement 8 9 11 5 10
Food Voucher 9 7 5 12 7
Individual mental health counseling 10 8 15 10 12
Med specialist 11 5 21 11 16
Medical case management 12 14 8 13 9
Prevention information at doctors office 13 22 12 7 8
Nutritional supplements 14 12 18 20 17
Referrals 15 13 23 16 11

1-67
Figure 1-34 Comparison of African American Service Need to ALL PLWH/A

Figure 1-35 Comparison between Latino Service Need and All PLWH/A

Figure 1-36 Comparisons between API/Other Service Needs and All PLWH/A

1-68
Top Service Needs: Risk Group Differences

Table 1-19 shows the differences in the reported service needs of different risk groups. There
are no significant differences between MSM and all PLWH/A in their ranking or percentages
reporting needing services

Among the top needs, MSM/IDUs rank needing individual mental health counseling and medical
case management higher than other risk groups. Like all PLWH/A they rank substance abuse
relatively low. Still, as shown in Figure 1-37, they are significantly more likely to report a
greater need for residential, outpatient, and methadone substance abuse services. They are also
significantly more likely to say they need individual mental health counseling (ranked 4
th
) and
workforce re-entry training. They are significantly less likely than all PLWH/A to say they need
medical reimbursement and prevention information at a doctors office.

The top ranked needs for IDUs are similar to all PLWH/A. However, they rank housing related
services higher, including housing information and independent housing, as well as non housing
related emergency financial assistance, buddy support, and bus tokens. As seen Figure 1-38,
they are significantly more likely than all PLWH/A to need several services. They are more
likely to report needing buddy services, bus tokens, non housing emergency financial assistance,
group and transitional housing. While their ranking for substance abuse programs are low, they
are significantly more likely to say they need outpatient and residential substance abuse
treatment, and detox and methadone services. They are also more likely to need spiritual
counseling and adherence assistance.

Heterosexuals rank prevention information at their doctors office, medical reimbursement, and
non-rent and utilities emergency financial assistance higher than other risk groups. Not shown in
the ranking table, the also rank taxi vouchers and van transportation high than other PLWH/A.
As seen in Figure 1-39, heterosexuals are significantly more likely to report needing taxi
vouchers, prevention services at their doctors office and with a health educator, day care for
their children, and translation services than all PLWH/A. These findings are consistent with the
ranking of females who represent the majority of heterosexuals.
1-69
Table 1-19 Comparison of Risk Group Ranking of HIV/AIDS Service Needs
Service Needs in the Past Year Rankings (1=top ranked 44=lowest rank)

All PLWH/A MSM
MSM/
IDU IDU Het
Outpatient med care 1 1 1 1 1
Dental 2 2 2 6 4
Psychosocial case management 3 3 3 2 2
Bus pass 4 4 6 3 3
Food pantry 5 5 5 4 5
Nutritional education 6 6 8 10 12
Independent housing 7 8 10 5 8
Med reimbursement 8 7 13 9 6
Food Voucher 9 9 7 8 9
Individual mental health counseling 10 10 4 14 13
Med specialist 11 11 12 12 10
Medical case management 12 12 9 15 14
Prevention information at doctors office 13 13 21 13 7
Nutritional supplements 14 14 11 22 24
Referrals 15 15 14 25 18
Housing information 16 16 15 11 19
EFA, not rent or utilities 17 18 18 7 15
1-70
Figure 1-37 Comparison between MSM/IDUs Service Needs and All PLWH/A

Figure 1-38 Comparison between IDUs Service Needs and All PLWH/A

Figure 1-39 Comparison between Heterosexual's Service Needs and All PLWH/A

1-71

Top Service Needs: SPAs

Figure 1-40 shows the top eight needed services by the total 2004 Needs Assessment Survey
PLWH/A sample across the eight SPAs. The figure indicates that:

All SPAs rated outpatient medical care as their number one most needed services except the
East SPA, which rated it second.
Dental care was the second most needed service among all PLWH/A and among PLWH/A in
the Metro SPA and San Gabriel. It was the top need among PLWH/A in the East SPA.
Above average need existed for case management services in all the SPAs except in the San
Gabriel SPA were less than two thirds of the PLWH/A felt they needed this service.
PLWH/A reported a greater need for bus passes in the Antelope Valley, Metro, and South
SPAs.
PLWH/A reported a greater need for DEFA in Antelope Valley, Metro, West, and South
SPAs.
PLWH/A reported a greater need for and housing information services in Antelope Valley,
Metro, South, and East SPAs.
PLWH/A in Antelope Valley tend to report higher services need than the total sample of
PLWH/A particularly for psychosocial and medical case management, medication
reimbursement, taxi voucher and DEFA.
PLWH/A in San Fernando Valley have a higher need for case management and HIV
prevention services.
PLWH/A in San Gabriel tend to report lower services needs than other PLWH/A however,
they report greater need for dental care, medical specialists, and HIV referrals and directory.
PLWH/A in the Metro SPA report slightly greater needs than average yet they share the same
top needs.
PLWH/A in the West SPA report HIV prevention services as their third most import service
need. They also rate medical case management and DEFA as a greater need than average.
Bus passes are the second most important services for PLWH/A in the South SPA. They also
report a higher need for van transportation and bus tokens.
Overall, PLWH/A in the East SPA report higher needs than PLWH/A in all other SPAs
except Antelope Valley.
In the East SPA and more than 70% report a need for outpatient medical care, dental,
psychosocial case management, bus passes, nutrition education, and individual mental health.
South Bay SPA PLWH/A have lower than average need for services, yet report a higher need
for medication reimbursement, food vouchers, individual mental health, and DEFA.
1-72
Figure 1-40 Top Service Needs by SPA

1-73
Top Needs by Stage of Infection

People living with HIV who have not progressed to AIDS reflects a different population than
those living with AIDS. They are more heavily represented by communities of color and
women. They are poorer, have lower education, and lower income. Both because of their stage
of infection and different demographics they have different needs. As shown in Table 1-20, the
top five needs of PLWH and PLWA are ranked the same.

After the top five, both PLWH and PLWA report a high need for nutritional education. PLWH
report a greater need for independent housing and prevention at a doctors office than PLWA.
PLWA report a greater need for food vouchers, nutritional education, medical reimbursement,
and medical specialists.

Table 1-20 Service Need by Stage of Infection
Service Needed in the Past Year Rankings (1=top ranked 44=lower rank)
All PLWH PLWH PLWA
Outpatient med care
1 1 1
Dental
2 2 2
Psychosocial case management
3 3 3
Bus pass 4 4 4
Pantry 5 5 5
Nutritional education 6 8 7
Independent housing
7 6 10
Med reimbursement
8 9 8
Food voucher 9 11 6
Individual mental health counseling
10 10 11
Med specialist
11 14 9
Medical case management
12 12 12
Prevention information at doctors office
13 7 17
Nutritional supplements
14 16 14
Referrals
15 19 13

The difference in service needs between PLWH and PLWA is shown in Figure 1-41, and are
ranked by the size of difference. The greatest difference is that PLWH report a greater need for
prevention at a doctors office and also for prevention information. They also have a
significantly greater need for workforce reentry and housing information.

PLWA report a greater need for medical specialists, adherence treatment, home health care and
food vouchers.
1-74
Figure 1-41 Comparison of Need between PLWH and PLWA

Awareness, Demand, Utilization, and Satisfaction with Care Services

In addition to asking participants if they needed the forty-four HIV/AIDS services shown in
Figure 1-32, participants of the survey were asked is they were aware of the service, asked for
the service, received them in the past year, and whether the services they received met their
needs. (See Attachment 10 and Attachment 11) Responses to these questions are shown in
Figure 1-42 through Figure 1-44.

The figures are ranked by expressed need (the gray background), going from most needed to
least needed. The percentage of participants who said they were aware of the service is shown
by the red line at the top of the chart. The percentage of participants who reported if they asked
for the service is shown by the dark blue bar. This is referred to as demand. The percentage of
participants who reported receiving the service is shown by the light blue bar, and this is referred
to as utilization. Finally, the percentage of participants who said that the service met their
need is shown by the green line, usually at the top of the chart. This is one measure of
satisfaction. The three charts are presented ranked by perceived need. Figure 1-42 shows the
awareness, need, utilization, and satisfaction for those services with a perceived need of over
50%. Figure 1-43 displays the same figures for those services where more than a third of
PLWH/A have a perceived need. Figure 1-44 shows the remainder of the services with lower
perceived needs.

There are some overall messages from these graphs:
The fact that the gray background on the graphs are almost always above the bars indicates
that PLWH/A say they need more service than they actually ask for or receive. The only
exception is that PLWH/A receive more prevention information from their doctor or health
educators than they perceive they need.
Awareness of an HIV/AIDS care service is higher than either perceived need or demand.
Between 80% and 90% of PLWH/A are aware of the care services they say they need the
1-75
most. Exceptions include a relatively low awareness of food vouchers (68% aware) and
medical case management (78% aware).
Awareness declines for services with lower reported need, demand, and utilization. The
services not funded by the Ryan White CARE Act are those with the lowest awareness
including non-housing related emergency financial assistance, spiritual counseling, buddy
support, health insurance assistance, and rental assistance. An exception to this observation
is the low awareness of advocacy and relatively low awareness of child care, and this may be
due to the general lack of understanding of the service by PLWH/A.
PLWH/A usually ask for more services than they receive. The opposite is true for prevention
at a doctors office, outpatient medical care, health education provided by an educator,
medical case management, medication reimbursement, and nutritional education.
The demand for services follows reported need, with those services needed the most asked
for the most. The exception shown in Figure 1-42, is food vouchers, where the need is far
greater than the demand for the service. This is probably due to the knowledge by
participants that the service is very difficult to obtain.
Among the moderate needs, (Figure 1-43) need tends to be quite a bit greater than demand,
with the exception of health education by an educator. For those services needed the least,
the reported need tends to follow demand and utilization.
The vast majority of those using the care services say it meets their needs (the green line).
The services with relatively lower satisfaction include housing information, legal services,
and child day care.

1-76
Figure 1-42 Consumer Awareness, Demand, Utilization, and Satisfaction of Most Needed Services

1-77
Figure 1-43 Consumer Awareness, Demand, Utilization, and Satisfaction of Moderately Needed Services

1-78
Figure 1-44 Consumer Awareness, Demand, Utilization, and Satisfaction of Less Needed Services
1-79
Service Gaps

In addition to the ranking of service needs, two gap measures were calculated for the needs
assessment.

First, the difference between what services are needed and what services are asked for
indicates a gap between what PLWH/A believe they need and their expectation of receiving a
service, and is referred to as the need-ask gap. PLWH/A may not ask because they know
or perceive that they are ineligible, feel that they have no access, or do not know who to ask
for in order to obtain the service. These barriers are explored later in the report.
Second, the difference is between what is asked for and what is received and is referred to as
the ask-receive gap. Large gaps can reflect the misperception of the consumer about their
eligibility for a service and/or the systems lack of capacity to provide requested services.
Organizational barriers are further explored in the following section.

Figure 1-45 displays those services that have a difference between what was needed and what
was asked for. It indicates that:

The overall message is that half the services have a need-ask gap of over 10%. Services with
the largest need-ask gap are non-housing related emergency financial assistance (32%), food
vouchers (26%), rent and utility related emergency financial assistance (23%), rental
assistance (22%) and advocacy (19%). Of these top five, three are not funded by Title I of
the Ryan White CARE Act. Further, the majority of rental assistance is funded by HOPWA
and other sources. The high need-ask gap for advocacy may be due to an unclear picture of
advocacy in the consumers mind, and the large gap for dental reflects difficulty of accessing
dental care.
The overall pattern that is shown in Figure 1-45 indicates that consumers are unlikely to ask
for services they know they are unlikely or cannot receive. The need-ask gaps that are in the
purview of the Commission to impact are some of the primary health care and removal of
barriers services, such as dental, food services, and case management.
In the primary health care core dental (18%), nutritional education (15%) and group mental
health (9%) have the largest need-ask gaps.
In the removal of services category, food and housing services are the most likely to have
need-ask gaps. Food services include nutritional supplements (18%), home delivered meals
(11%), and food pantry (10%). Housing services include housing information (14%) and
independent housing (11%). Taxi vouchers (17%) also have a significant need-ask gap.
All the patient care coordination services have need-ask gaps with PLWH/A reporting that
they need referrals from directories 16% more than they ask for them. Medical case
management (14%) and psychosocial case management (10%) also have a higher perceived
need than demand.

1-80
Figure 1-45 Need Ask Service Gaps
0.0
%
5
%
10% 15
%
20
%
25
%
30
%
35
%
N-hsing
EFA
Food
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asst
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y
Denta
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Nutri
sppl
Taxi
Vchr
Wrkfce
entry
Dirctry
Budd
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info
Van
Transp
Spirtl
cnsling
Lega
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Prev@Dr
.
Hme Dlvd
mls
Ind
hsing
Peer
cnsl
Food
pantry
Psysoc
CM
Primary Health Care
COre
Removal of Barriers
Unfunded by RWCA Title I
Economic Well-being
KEY
1-81
Figure 1-46 displays the ask-receive service gaps. The bar line to the right indicate that a
PLWH/A asks for but does not receive a service. They are ranked in size of gap from the bottom
to the top of the graph. The five services at the top of the graph with bars going tot the left
indicate that that PLWH/A report receiving these services even when they dont ask for them.
This figure indicates:
Overall most services that are asked for are received. The largest gap is 18% of those asking
for independent housing do not receive it. As seen in the last section, independent housing
also has a significant need-ask gap. Given the overall shortage of housing in Los Angeles
among those with low income, the degree to which this situation can be mitigated by Ryan
White CARE act funds is limited.
PLWH/A noted a gap in food services in 2002, and they continue in 2004. Food vouchers,
no longer provided by the CARE Act, have the largest gap (9%). The gap for nutritional
supplements is 7% and the gap for food pantry and home delivered meals is less than 5%.
Housing and food services that receive Title I Ryan White CARE Act funds have the largest
ask-receive gaps, and this reflects the populations shift in PLWH/A as those impacted by the
epidemic are shifting to lower income populations.
Repeating the finding from 2002, outpatient medical care is received more than it is
requested. The likely explanation is most PLWH/A dont ask for the service; rather
appointments are routinely scheduled.
PLWH/A report that nutritional education and medical case management are received more
than they request them. Like outpatient medical care, this is possible because providers are
mandated to provide nutritional information and usually provide medical case management
as part of regular outpatient care. While the need-ask gap indicates a higher perceived need
than demand for these services, this chart shows that once asked for, it is received. This
suggests a need to improve awareness of these services.
Among the primary health core, dental services had a gap of 9% and individual mental health
counseling had a gap of under 5%. Both are about the same as reported by PLWH/A in
2002.
Legal services had about the same gap, 6%, as reported by PLWH/A in 2002.

To better understand these gaps, the next section discusses general barriers to the system. The
conclusion of this report will also pull these findings together and suggests some possible actions
to overcome these gaps.
1-82
Figure 1-46 Ask-Receive Service Gaps

-
25%
-
20%
-
15%
-
10%
-
5%
0
%
5
%
10
%
15
%
20
%
Ind
hsing
EFA
rnt/util
Rent asst
Food
Vchr
Hsing
info
Denta
l
Nutri sppl
Lega
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Taxi Vchr
Wrkfce
entry
Hme Dlvd
mls
Food pantry
Nutri
ed
Med
CM
HER
R
Outpt med
care
Prev@Dr
.
Primary Health Care
COre
Removal of Barriers
Unfunded by RWCA Title I
Economic Well-being
KEY
1-83
BARRIERS

The PLWH/A participating in the 2004 survey were to rank 31 different potential problems on a
scale ranging from not a problem to a very big problem. These barriers were not linked to
a particular service category. As shown in Table 1-21, the thirty-one potential problems can be
classified into the more general categories of organizational, structural, or individual
barriers.
Structural barriers are further subdivided into rules and regulations and levels of access.
Rules and regulations include insurance coverage, cost of services, bureaucratic challenges
(red tape), eligibility and problems navigating the system of care. On average, about 35%
of the PLWH/A are likely to have a problem with these types of barriers. Structural access
barriers have to do with lack of transportation, access to specialists or lack of family-oriented
services. These are mentioned less frequently than rules and regulations but still about
18% of PLWH/A registered they had a problem with these types of barriers.
Organizational barriers are subdivided into 1) provider sensitivity and 2) provider expertise.
Sensitivity barriers include the providers response to the PLWH/As issues and concerns,
making the client feel like a number, rather than an individual, and helpfulness of the
provider. On average, over a quarter of the sample (28%) reported experiencing this type of
barrier. Provider expertise includes the perceived experience of providers, ability to provide
correct referrals and ability of providers to get along with clients. On average, nearly 30% of
PLWH/A note that they have experienced these types of barriers.
Individual barriers are subdivided into 1) knowledge and 2) well-being barriers. Knowledge
barriers refer to the individuals knowledge about treatment and access. About 40% of the
participants reported problems with these types of barriers. Well-being refers to physical or
mental well-being. About 38% of the PLWH/A mention well-being barriers.

Table 1-21 displays the percent of PLWH/A who report a problem with each of these barriers.
For those with a problem it shows the percent who say it is a big problem and the average score
for the height of the problem that ranges from one, a very small problem, to 6, a very big
problem. In general the table says that while there are many barriers to receiving care, none are
seen as more than moderate barriers.

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Table 1-21 Types of Barriers
OF THOSE WITH A
PROBLEM
1=Very small, 2=Small, 3=Moderate, 4=Big, 5=Very big

STRUCTURAL
% WITH
PROBLEM
% WITH
BIG
PROBLEM
AVERAGE
BARRIER
SCORE

Rules and Regulations
1. Too much paperwork or red tape. 42.5% 36.0% 2.9
2. The amount of time I had to wait in a waiting room before I received
the services. 39.3% 30.8% 2.7
3. My lack of, or inadequate, insurance coverage. 38.8% 50.5% 3.3
4. Too many rules and regulations. 33.7% 41.8% 3.0
5. I could not afford one or more of the services. 33.7% 49.9% 3.3
6. My inability to find my way through the system. 33.1% 26.8% 2.6
7. The amount of time I had to wait to get a doctors appointment once I
was diagnosed with HIV 26.4% 30.2% 2.6
8. Could not prove eligibility for the service. 26.2% 45.3% 3.2
Access
1. No transportation. 29.1% 33.7% 2.8
2. There was no specialist who could provide the care I needed. 23.0% 41.1% 3.0
3. I was terminated or suspended from seeking services. 16.4% 46.8% 3.3
4. I have been denied or have been afraid to seek services due to
criminal justice matter. 13.6% 32.5% 2.6
5. No childcare. 6.1% 28.4% 2.3

ORGANIZATIONAL
Provider Sensitivity
1. Fear of my HIV or AIDS status being found out by others - lack of
confidentiality. 29.1% 40.9% 3.0
2. The service provider or persons providing services was insensitive to
my issues and concerns. 23.0% 28.6% 2.7
3. The people providing services to me were not helpful. 16.4% 27.3% 2.6
4. The organization providing the service made me feel like a number. 13.6% 41.4% 3.0
5. Discrimination I experienced by the persons or organization providing
the service. 6.1% 39.5% 3.0
6. Fear that I would be reported to immigration or other authorities. 15.0% 40.0% 2.7
Provider Expertise
1. Lack of experience or expertise of the person providing services to
me. 32.3% 34.1% 2.8
2. The organization did not provide the right referrals to the services I
need. 27.9% 30.6% 2.7
3. I did not get along with the people providing services to me. 27.2% 21.0% 2.4

INDIVIDUAL
Knowledge
1. Not knowing that a service or treatment was available to me. 51.0% 28.1% 2.8
2. Not knowing a location of the service(s). 46.2% 31.3% 2.8
3. Not knowing who to ask for help. 42.4% 37.3% 3.0
4. Not understanding the instructions for obtaining the service or
treatment. 40.7% 28.7% 2.7
5. Not knowing what medical services I need to treat my HIV infection or
AIDS. 32.5% 33.7% 2.7
6. My inability to communicate or interact with the service provider. 21.9% 29.6% 2.7
Well-Being
1. My physical health has not allowed me to get to the place where the
service is provided. 38.4% 27.7% 2.6
2. I do not believe HIV or AIDS is a problem for me that require
assistance. 37.5% 34.1% 2.9
3. My state of mind or mental ability to deal with the treatment. 37.4% 31.6% 2.8

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This data is shown graphically in Figure 1-47, where the % of PLWH/A reporting a problem is
shown by the bar, and the average height of the problem by the line. Like the table, it is
organized by the three major categories of barriers, and the 6 subcategories of barriers.

Figure 1-47 graphically shows the range of organizational, individual, and structural barriers
reported by PLWH/A.
Among the rules and regulations, structural barriers, over 40% of PLWH/A report that red-
tape and lack of insurance coverage are barriers that impact their ability to receive care
services. For those who report cost is a barrier, nearly half say it is a big barrier. Similarly
for those who are terminated from service, this presents a high barrier for obtaining services.
The other structural barriers are ranked as small to moderate barriers.
In general, among the structural barriers, more PLWH/A report barriers reflecting the rules
and regulations in the care system than access barriers, like transportation and unavailability
of child care.
From the three groups of barriers, PLWH/A are most likely to claim one or more individual
level barriers like knowledge and well-being. About half of the participants report that their
lack of awareness of the availability of treatment and lack of awareness of the location for
services is a barrier for obtaining needed services. About a quarter of those saying it is a
barrier, rate it is a big barrier. On average they are moderate barriers.
Over a third of the PLWH/A report that their physical well-being presents a barrier for
obtaining services. For them, their physical health, state of mind and denial about their HIV
and AIDS status present a moderate barrier, with over a third of those reporting denial saying
it as a big problem.
Among all the barriers listed, less than a third of the PLWH/A name any single
organizational barrier. For those reporting confidentiality, fear of authorities, discrimination
and feeling like a number, it is among the highest organizational barriers they face.
Compared to 2002 fewer PLWH/A name significant barriers to receiving their care.

For more information on how different subpopulations report barriers, please refer to Attachment
10 and Attachment 11. Following are consumer forum comments, organized by barrier category.

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Figure 1-47 Barriers to Services
1=Very small, 2=Small, 3=Moderate, 4=Big, 5=Very big

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Barriers to care were further explored in the eight focus groups among diverse populations held
in 2004. Below is a list of comments that add some depth to findings reported above.

Structural

Barriers

Rules and Regulations

Across many of the service categories, H-CAP survey respondents had similar problems. Of
these, rules and regulations were a common problem. Many echoed the message of cutbacks in
HIV/AIDS care, saying services are limited due to funding cuts and staff changes or that they
were on the waiting list. Many note they are not eligible for the service, sometimes because
of their undocumented status. Among the reactions of undocumented clients include, legal
services? Come on, Im undocumented. They dont exist for me and (The agency) can never
do anything if you are undocumented. We do not have rights in this country. They treat us
really harshly and they dont want us in (the U.S.). Within many service categories, clients cite
too much paperwork, saying that I dont even bother anymore. It takes so much time to
complete the paperwork and then you are probably not even eligible.

Limited Services

An African American MSM/W says When I got out of treatment in March, I was having a very
difficult time. When I was living in Pasadena I would go to (name of agency) and I could see a
psychiatrist. Since I'm in Pomona now, Im at (name of agency) and we dont have a
psychologist and I was having some major stuff going on with memory and just everything. There
was really nothing and no one for me to see. A lot of the services that were listed (on the survey)
weren't available.

An African American IDU Male says the service availability is, steel prejudice. He says, You
can't get in the black neighborhood, which is considered South Central, what you get on the
outside. I go on the outside because I know better. I don't try to go to South Central because its
against me. You can go anywhere as long as you stay on the outside, but if you try to go in your
neighborhood in South Central, you're asking for trouble. You're not going to get it because they
don't have it and they're not ever going to give it to us. He adds, They have a great program
that they started working on at (name of agency) but they are so lacking in funding. One of the
guys who is a director of projects there, he is a member of our group, but the horror stories that
he tells, its like pulling teeth just to get them enough money even to do paper work to print
pamphlets to put the information out there, not to mention to get the condoms to pass out. They
can't get anything. Once you get into the Afro-American neighborhood in South Central and
beyond, you can absolutely forget it.

A Latino MSM, responding to the question of what service would he cut if he had to cut a
service, says, At least for me, we have to have some consciousness. People who are citizens
here get everything, health, housing, etc. That's fine; they've worked for it, whatever. But I get
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very little and I'm really thankful, but I need it all. Do you understand? Sometimes the nurse asks
me if I want to take the taxi, but I still take the bus because those services should be saved for the
people who need them.

Ability to find my way through the system

An African American heterosexual female, There should be some kind of activist that could
help fight for us. I shouldn't have to be on the phone all day stressing and trying to call and get
to the top person. It should be somebody that fights for us. And that's what I'm going to do once I
get myself together because this is not fair. They tell us don't stress because it affects our T-cells,
but they do everything to make us stress.

Red Tape

An African American MSM/IDU says, I have a dentist, but the problem with dental care is
when you go see a dentist they'll need the paper work and then you have to go see another
dentist to see if you can get the paperwork done. My dentist is actually 2 blocks from where I
live. I had to go to Burbank to get an OK from another dentist which took 5 minutes. The cab
company had to take me out there.

Amount of time

An African American MSM says, I want to agree with what the gentleman said before (name
of agency) -- their services are all generally slow. You're waiting to see a doctor and it takes you
well in excess of an hour, hour and a half.

Eligibility

An African American heterosexual female says, I don't have MediCal. They say I'm not going
to get MediCal because I don't have AIDS. (I have a) one bedroom, but I don't get Section 8
because they say even with my unemployment; I'm at thirteen-hundred a month, which is not a
lot of money for me at all, but they say, Oh, you don't qualify. You make too much money.

Afraid of being reported to immigration

A heterosexual Latino says, You just have to look (services) up, because there are a lot of
services that you can get. You can get all your medicines covered if you're a legal resident or a
citizen. If you're illegal, you are a burden to the government, so you can't get everything. So if
you're legal and sick, they give you housing, transportation, food, a salary, everything. But if you
are doing all the paperwork for the residence, being HIV positive will not be good for your
papers. In my case, I'm applying, and if they find out, they won't give it to me. It's not only about
asking for help, because everyone wants to come here to get help for HIV, and until the day that
there's a cure and it is sold in the pharmacies, we'll be a burden to this government. My friend is
a legal resident, and he can't get his citizenship because he would be a burden for the
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government. He talked to the lawyers, and they told him it's going to affect you if you apply for
housing. Not if you only get the medicine, though."

Levels of Access

A Latino MSM says, Services that I really think are really important besides medical services,
is also information. Not information on prevention because we are saturated with that,
information to the community clinics, to the clinics where the people go, on housing and other
services that are provided. Because a lot of people are not aware of these services. And also
there are a lot of people who are afraid to go because they do not qualify for MediCal, they dont
have papers or they feel that they will be reported to immigration.

Organizational

Organizational barriers are mentioned by fewer PLWH/A than structural or organizational
barriers. As shown in the quotes for the focus groups below, for those who have them, they tend
to be quite significant.

Provider Sensitivity

Sensitivity

An African American heterosexual female says, I go to this man gynecologist and I told him
I'm HIV positive and I could tell by his attitude that he was totally against that. He says, Well,
you know safe sex. I said, Well, do you know anybody with it? He says, Well, I'm a doctor. I
said, Is there anybody that you love that is positive? Well, no. I said, Well, that's why you
feel the way you do, I said, "But I'm going to tell you something. This virus is for everyone.
And you're married. It's still for you because that's where I got it from, from my husband that
loved dearly. You understand?

Another African American heterosexual female says, I was the only woman every time I went to
a clinic to do something. There wouldn't be no other woman there. So, I was like, Well, hell,
am I the only woman? And that's why I went to the directory to find other places to go, because
all the services were for men. When you can't do a pap smear, you know you're in trouble. I
know you've done seen a vagina. Open up and see what's happening. Do a thing in there. Do a
culture." She told me, she said, No, we don't do them. She said, I don't even know how to hold
the thing. And when she pulled it out I said, You're right. Let me pull my underwear back on.
"Uh-uh. You're going to hurt me. So, I said, No. I had to find out what was out there for
women and children.

A Latino IDU says, I understand that I have to do most of the footwork, but (if you walk in
there) you got somebody that is sitting behind the desks just thinking you owe them something
and all you're trying to do is seek help. Same thing at the welfare office. They think you owe
them something. And the man could look at me and tell that I do not trust the system.

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Feel like a number

An Anglo MSM/W says, (Name of agency) is so big, they have so many clients that they are
not able to deal with you on that one-on-one level, on that personal level. That's why I picked an
agency that was small. The clientele every year for my agency is 2,300.

Discrimination

An African American MSM/IDU says, The reason I left there was because it was obvious that
they were prejudiced and it was obvious that me being black was meaning that I was the last
thing on the totem pole to be seen. If they had nothing else to do and if they had time, then they
would see me and that was not acceptable. So I left and I stayed home and got really sick and
they took me to the emergency (room).

An African American MSM says, I was wearing a diaper and I see this (agency) over there,
home health care services. These two prim and proper white girls came out (to the waiting
room) and they ask you questions and they notice the bag of garbage (I have with me). They ask
me about the garbage and I say I will take it out I was refused on that alone. I was walking with
a walker with wheels on it. I was deathly ill. I weighed about 142 pounds and I was refused and
right. Now in my occupation delivering prescriptions to residences, I'm delivering to guys who
make it to the gym everyday paid for by (name of agency). They get those gym passes for 24-
hour Fitness or Bally's. These guys go the gym everyday and they got in-home health care. They
get extra money for people to come to their house to clean their house and make their beds and
they're running to the gym everyday. It pissed me the hell off when I saw that.

An African American heterosexual female, speaking of her interaction with providers, says, Be
more humane. That's all. Show eye contact, you know. You don't have hug us, but you could at
least look at us when we're talking to you. Things like that are very important to me. What am I
supposed to tell you? I'm positive. Look over here, you scared too. Youre putting on gloves.
You don't want it either. You think we want this? We don't want this. And we can give it to you.
But we give it to you. We don't want it. You can't get rid of it. You are not the same anymore.
It's past a racial thing. Okay, I can deal with being black. I can deal with being poor, fat,
whatever. Don't give me that. I'm no longer even human, okay, because now I can give this to
someone else and hurt them. That's not right.

A Latino MSM says, The social worker there was really extremely nice. She filled out the
paperwork for me and I took it to the Social Security office in. They told me they couldn't help
me because I wasn't their color.

Provider Expertise

In various different services, there were many H-CAP respondents who say the service provider
is mean and rude, or as if you owe them something. This was a problem cited across all
service categories by all different clients.

1-91
An African American MSM/IDU says, Some of the things that need to be addressed is the
doctors being aware that you have had substance abuse. I recently saw a psychiatrist and I told
her about my substance abuse and she practically ignored it. I told her I'm in an addict. I am
(at the appointment) for less than thirty minutes and she prescribed Vicodin. I can't go there for
help. The guy who came in after me died a week later from an overdose. I went to see her one
more time - I talked to a therapist and a nurse and I saw her one more time. She prescribed
another medication. He continues, What really had me angry with her is I told her I'm
suffering from lyphodystrophy. This medication that is supposed to help my depression is going
to make me gain weight. Why am I depressed? Because of the lyphodystrophy. Why are you
giving me medication that I will gain weight?

A Latino MSM says, The doctor again just really didn't care. I had an appointment with him
and instead of him telling me where to go or what to do or where was any information that I
wanted, he just said, I don't know. I don't know. I kept asking him how (to go about it). He
didn't tell me anything about where to go or how to get help. Even though I inquired about it he
still didn't know and he refused to give me information.

Individual

Individual barriers, particularly lack of knowledge about services and location of providers or
who to ask for services were cited by about 40% of PLWH/A. In general they are moderate level
problems, but as noted below, for particularly Hispanic populations, these barriers can be
formidable.

Knowledge

In all the services, H-CAP questionnaire respondents frequently mentioned being unable to
communicate with service providers because of a language barrier. Many cited not being able to
access services such as client advocacy, individual mental health appointments, and legal
services due to the agency not having bilingual staff. In many cases, monolingual Spanish
speakers say their doctors cannot communicate to them in Spanish, but rather than allowing
another person to translate, which would be an intrusion on their confidentiality, they do not
understand the content of their medical appointments.

Another frequently cited problem was not knowing that the service exists. Many participants of
H-CAP felt that their case manager would not tell them about the service, that the case managers
were not helpful for not offering the service. When finding out about the service, many feel
distrust towards the case manager for withholding information, and in turn do not know who to
ask for help.

An English-speaking Latino IDU says, There are a lot of things that the Latino community does
need as far as assistance: some of them that don't speak proper English, the medications that
they need to be aware of, and the symptoms and the diagnoses of the virus that they are so
afraid, or they may be infected and come up and explain to family members that may not
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understand. But it's a community where they need to start recognizing that this is a reality that
we deal with. It's not anything wrong or dangerous to others unless you make it that way.

Well-Being

While few participants discussed physical health as a problem in accessing services, many did
talk about the period before they entered care. Their state of mind and mental ability to deal with
the treatment is discussed below.

A Latina transgender (MTF) says, Desperation from the bondage of my hell that was induced
with my own hand and living with HIV, my own depression, my own psychological thoughts, plus
the drugs and alcohol. (What would get me into care earlier?) Just getting older and knowing
better. Just needing to break away from the drugs and alcohol. I just needed that last kick in the
ass by the disease to get me on the right track.

A Latino MSM says, There are a lot of people out there that still don't understand that there is
help out there. Because a lot of people are worried about money or they don't have insurance
and they figure, I can't get help. But you just need to get someone to get you to that door, a
phone call. That's the reason why I couldn't (get back into care). I didn't want to go to the
doctor because I thought he would probably tell me, Well, you need to do this and do that.
You've got to start somewhere. And a lot of people are kind of scared. They are kind of shy or
like me, embarrassed to go up someone and ask for something.
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SPECIAL POPULATIONS

The following section presents the profile of nine special populations of PLWH/A in Los
Angeles County. These are special populations have unique needs and challenges to
obtaining HIV services and or populations that are disproportionately impacted by the
HIV epidemic. For instance, as shown in Table 1-22, MSM of Color represent about 2%
of the Los Angeles County population, however, they account for about 55% of the
PLWH/A. The table also shows that among the MSM of Color, almost 10% are living
with HIV/AIDS.

Table 1-22 Special Population Estimates
1
Special
Population
Estimated
population
in LAC
Estimated
Percent of
Total LAC
Population
Estimated
number
living with
AIDS
Estimated
number
with HIV /
AIDS
(aware)
Estimated %
of Total Pop
PLWH/A % PLWH/A
TOTAL POP 10,008,000 100.0% 19,752
3
42,000
2
.4% 100.0%
MSM of Color 222,000 2.2% 8,300 23,000 10% 54.8%
MSM- Anglo 108,000 1.1% 6,100 10,300 9.50% 24.5%
Recently
Incarcerated 165,000 1.6% 1,500 4,400 2.70% 10.5%
Women of
Childbearing
Years 2,449,000 24.5% 1,500 4,900 0.20% 11.7%
Youth 13-24 1,560,000 15.6% 220 2,100 0.10% 5.0%
IDU 166,000 1.7% 2,800 6,100 3.70% 14.5%
Non-IDU
Substance Users 219,000 2.2% 1,100 3,300 1.50% 7.9%
Homeless and
Unstably Housed 236,000 2.4% 3,300 8,300 3.50% 19.8%
Serious Mental
Illness 343,000 3.4% 1,100 3,200 0.90% 7.6%
Transgender 10,000 0.1% 550 1,700 17% 4.0%
Undocumented 733,000 7.3% 800 2,500 0.30% 6.0%
1 Estimates for the special populations were provided by the HIV Epidemiology Program, Los Angeles County
Department of Health Services
2. From HIV Epidemiology estimate of BRG
3. HARS, As of June 2004

Nine special populations are profiled in the following text including 1) Men of Color who
have sex with men, 2) Recently Incarcerated, 3) Undocumented, 4) MSM, 5) Latino/as or
Hispanics, 6) Severely Mentally Ill, 7) Women of Child bearing age (18-49), 8)
Homeless, 9) Youth (18-24). These populations were identified as special need
populations in the Ryan White Title I grant application for Year 15. Additional
populations identified as a special population also include substance users, transgenders,
those multiply-diagnosed with HIV, substance use and mental illness; sex workers; and
African-Americans.
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Men of Color Who Have Sex With Men (MSMC)

Non-Anglo Men Who Have Sex with Men include African American, Latino, API, and other
non-Anglo men who identify as gay or report having contracted HIV from a man. Unlike the
MSM category under risk groups, MSMC include MSMC injection drug users as well.

Demographic Profile
MSMC represent 45% of the sample population. Based on HIV Epidemiological
estimates, MSMC represent about 55% of all PLWH/A.
11
A high percentage (46%) of the
sample was born in Mexico/Central America, followed closely by those born in the
United States (47%). A significantly smaller proportion was born in South America
(3%), Asia (2%), Africa and the Caribbean (1% each). Consistently, 64% of MSMC
identifies their racial or ethnic background as Hispanic or Latino, 32% as Black and 4%
as Asian.
The mean age of the sample is 40. Eighty-five percent (85%) are between the ages of 20
and 44 years, and those 45 years or older make up the remainder of the sample (15%).
The educational level of MSMC is similar to other PLWH/A with 28% reporting not
completing high school or obtaining a GED. Twenty-six percent (26%) are employed
either part or full-time, and their income tends to the lower end with 61% making less
than $9,000 a year and 33% between $9,000 and $18,000.
Like other PLWH/A, most MSMC live in an apartment or house they rent (64%), and 7%
reside in an apartment or house they own. Slightly more than one-fourth of the sample
lives with a partner (27%), and those who live with a partner or lover who is also HIV
positive comprises 46%.
Almost half of MSMC are uninsured (49%), and 39% report Medical or Medicaid
coverage.

Physical and Emotional Health
Fifty percent (51%) of MSMC feel that their physical health is good to excellent, and
around two-thirds (63%) report their physical health has improved since they first sought
treatment. Emotionally, about half (47%) of all MSMC report having good to excellent
emotional health currently, and 57% feel their emotional health is better now than when
they first sought treatment.

Stage of Infection
The majority (53%) of MSMC, like other PLWH/A, have generally been HIV positive
for more than eight years.
Under half of the MSMC (43%) report a diagnosis of AIDS, and nearly half (46%) report
disabling symptoms.

11
Two hundred and sixty-eight (268) Men of Color who have Sex with Men (MSMC) completed the 2004 HIV/AIDS Care
Assessment Survey. For analysis the data is weighted to bring risk groups back to proportion, and because we oversampled
heterosexuals, MSM were weighted up, resulting the equivalent of an N of 332 MSMC.
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Medication Adherence

The significant percent of MSMC (76%) are currently taking antiretrovirals or protease
inhibitors, and approximately one third (30%) are taking antibiotics to fight off infections.
As with other PLWH/A, 30% have stopped seeing a doctor for six months and 22% for a
year, since their diagnosis. Thirty-seven percent (36%) indicate never skipping their
medication, and over one-half (58%) indicate forgetting to take the medications as the
number one reason they do not adhere to their medication regimen.

Co-Morbidities

Over half of MSMC (57%) who have consumed alcohol have used alcohol within the last six
months, with 24% consuming at least once a week. Nearly a quarter (24%) of MSMC
indicate continuing marijuana use within the last six months with 21% reporting use of once
a week or more.

STD rates and mental health problems are lower within MSMC than amongst all PLWH/A.
They show a lower rate of Hepatitis C (9%), and also a smaller proportion has been
diagnosed with depression (50%) or anxiety (33%) within the last two years.

Top Service Need

Figure 1-48 shows the top ten service needs for MSMC who completed the 2004 Care
Assessment Survey, which includes five primary health care services. MSMC seem to have
service needs that are very similar to other PLWH/A, though their reported need for these
services is slightly higher. The top five needs are: outpatient medical care (92%), bus passes
(81%), oral healthcare (78%), benefits case manager (76%) and food pantry (68%).

Figure 1-48 Top Service Needs for MSMC

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Barriers

Using a five point scale where 1 indicates a very small problem in seeking care and 5
represents a very big problem, participants were asked to rate 31 items in terms of the level
of difficulty they represented for them when trying to access care. The following table shows
the top five barriers along with the average score indicating the size of the barrier each of the
items represented for them.

MSMC show a slightly higher tendency to report problems in getting services than other
PLWH/A. Shown in Table 1-23, three of the top five barriers are individual barriers, and the
other two are organizational. Half of the MSMC report not knowing that a service or
treatment was available, and it was a moderate problem for those reported it. This was
followed by 48% of MSMC who reported a problem with paperwork or red tape. Forty-six
percent (46%) reported a problem of inadequate insurance and for those with this problem is
was a relatively high barriers.

Table 1-23 MSMC: Top Barriers to Care
REASON
% with Problem
Average Score
5=very big 1=very small
Not knowing that a service or treatment was
available to me
50.0% 2.9
Too much paperwork or red tape 48.1% 2.8
Not knowing who to ask for help 47.4% 2.9
Not knowing a location of the service(s) 46.7% 2.8
My lack of, or inadequate, insurance coverage 46.2% 3.1

Recently Incarcerated

Recently incarcerated are defined as PLWH/A who report being in jail sometime in the last
two years.

Demographic Profile
About 12% of the sample reported being in jail sometime in the last 2 years.
The distribution of males and females is similar to all PLWH/A, 8% are male and 14%
female.
Compared to all PLWH/A, those incarcerated in the last two years are more likely to be
African American. Still the largest number, 37%, are Hispanic, followed by 35% Black,
and 25% Anglo.
Recently incarcerated are over twice as likely as all PLWH/A to be infected through IDU
(18%).
While half the recently incarcerated report being gay, they are more likely than all
PLWH/A to report being heterosexual (30%) and bisexual (17%).
Recently incarcerated have about the same education level as all PLWH/A, Twenty-eight
(28%) did not graduate high school or obtain a GED, 33% have a high school diploma or
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obtained a GED as their highest level of education, and 39% report some higher level of
education.
Compared to all PLWH/A recently incarcerated are much more likely to report not
working and not looking for work (60%). Fifteen percent (15%) report being employed
either part of full time and 23% are not working but looking for work.
The income of the sample is lower compared to other PLWH/A, with 67% making less
than $9,000 a year compared to 50% for the sample as a whole.
People living with HIV/AIDS who have been recently incarcerated report a harder time
than all PLWH/A finding stable housing. Just over a third (39%) lives in an apartment or
house they rent, and 38% is either homeless or in transitional housing (e.g. crashing
with someone without paying rent, a single resident occupancy or a half-way house).
Over 20% report that their living situation is neither safe nor stable; this is not surprising
since 59% reports being homeless within the last two years, and 47% has been in
transitional housing during the same period of time.
Significantly more recently incarcerated are uninsured compared to all PWLH/A. Nearly
half (49%) of the recently incarcerated PLWH/A currently do not have any health
insurance, and 40% reports Medical or Medicaid coverage.

Stage of Infection
Most of the recently incarcerated PLWH/A (55%) have been HIV positive for more than
eight years. About the same number of recently incarcerated as all PLWH/Afound out
less than a year ago (7%).
More recently incarcerated (54%) report disabling symptoms than all PLWH/A (47%),
45% have received an AIDS diagnosis.
Recently incarcerated are less likely than other PLWH/A to feel their physical health has
improved since they first sought treatment for their HIV, with 30% reporting that they
feel worse now than before treatment, (compared to 20% of all PLWH/A) and a quarter
reporting no difference. Half of the sample (50%) would describe their emotional health
as fair, though 53% feel it has improved since they first sought treatment for HIV.


Compared to other PLWH/A, recently incarcerated are more likely to have been out of care
over six to twelve months since being diagnosed with HIV disease. Fifty percent (50%) have
stopped seeing a doctor for at least six months and 32% for over a year since their diagnosis.
A lower percent (54% compared to 76% of all PLWH/A) report being on antiretrovirals or
protease inhibitors.

A relatively high percentage (22%) of recently incarcerated report currently stopping their
medication regimen when compared to all PLWH/A (7%). This is supported by focus group
comments where those recently incarcerated note the inconsistent treatment of HIV within
Californias criminal justice system. While 11% of all PLWH/A report not being prescribed
medication, 18% of recently incarcerated report not being prescribed medication. The
primary reason for skipping their medication is their doctor advised them to stop taking their
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medications (34%), which can be explained by the higher rates of hepatitis C and drug use in
this population, and the lack of concern showed by the doctors in jail, repeatedly reported by
the participants of the study. The other reasons for skipping or stopping their medicine are
forgetting (35%) and side effects (22%).

Co-Morbidities

Recently incarcerated PLWH/A report higher rates of STDs than all PLWH/A. The rate of
reported Hepatitis C (35%) is over twice that found among all PLWH/A (15%). Nineteen
percent (19%) have had hepatitis A or B in the last two years, and 14% report having genital
herpes.

Eighteen percent (18%) of recently incarcerated indicates sharing needles as their probable
cause of infection. Over one third (36%) of the recently incarcerated living with HIV/AIDS
report a history of injection drug use, compared to 15% of the total PLWH/A sample.
Crystal meth has the highest continued use with 14% reporting use of it in the last six months
and, among those, 12% using it once a week or more. Few (3%) report heroin use.

Many of the recently incarcerated have a history of mental illness in the past two years.
Sixty-six percent (66%) have been diagnosed with depression, 45% with anxiety, and 30%
bipolar disorder. Furthermore, 32% report Other diagnoses, a category that includes severe
mental health problems such as schizophrenia.

Like all PLWH/A, over 80% of the recently incarcerated report receiving individual mental
health counseling since diagnosed with HIV, and 76% have been prescribed medication for
their mental health problem. A significantly higher percentage of recently incarcerated than
all PLWH/A (39%) have been admitted for mental health problems.

Top Service Need

Figure 1-49 shows the top ten service needs for the recently incarcerated PLWH/A, which
includes five from the removal of barriers core, four primary health core services, and one
patient care coordination service. The top five needs are: outpatient medical care (94%), bus
passes (88%), benefits case management (84%), food pantry (79%), and individual mental
health (75%).

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Figure 1-49 Top Service Needs Among Recently Incarcerated

Barriers

Using a five point scale where 1 indicates very small problem in seeking care and a 5
of difficulty they represented for them when trying to access care. Top rated barriers are
shown in Table 1-24. The two largest problems experienced were their state of mind to deal
with the treatment and not knowing a location of the service. Although fewer (51%) of
recently incarcerated say that lack of insurance is a problem, for those with tat problem it is a
big barrier. In general, recently incarcerated PLWH/A report more problems in getting
services than other PLWH/A, and they give those problems higher difficulty ratings.

Table 1-24 Recently Incarcerated: Top Barriers to Care
REASON
% with Problem
Average Score
My state of mind or mental ability to deal with
the treatment
60.8% 2.8
available to me
58.4% 3.4

Undocumented PLWH/A

Of the 732 participants in the survey, 123 reported they were undocumented. In the weighted
analysis undocumented still are over-represented and represent nearly 15% of the PLWH/A.
HIV Epidemiology estimates that undocumented represent under 5% of all PLWH/A.
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Demographic Profile
Most of the undocumented in the sample are males (91%). The vast majority (94%) were
born in Mexico/Central America, 5% in South America and 1% in Africa. Not
surprisingly, 97% of undocumented PLWH/A describe their ethnic background as
Hispanic or Latino/a, followed by 2% that identify as Black and 1% each as Anglo or
Asian.
The mean age of undocumented PLWH/A is 35. Youth (18 to 19 years old) represent
only 1% of the sample, those between the ages of 20 and 44 years make up 92% and
those 45 years or older make up 7% of the population.
Far more undocumented (44%) have not completed high school or obtained a GED than
all PLWH/A. Nevertheless they have a much higher employment rate (37%) than other
PLWH/A (21%). A high percentage (39%) is looking for work.
Despite their higher employment rate, undocumented living with HIV and AIDS are
much more likely than other PLWH/A (82% compared to 50%) to have an annual income
of less than $9,000.
Most of the undocumented PLWH/A (64%) live in an apartment or house they rent, and
7% in an apartment or house they own. Their living situation is mostly habitable (90%),
similar to other PLWH/A, but unlike the broader sample, a higher percentage feel their
housing is unstable (29%) and unsafe (23%).
More undocumented (84%) than all PLWH/A feel they contracted HIV by having sex
with a man. This corresponds to the fact that 59% of the undocumented PLWH/A
consider themselves gay and 18% bisexual.
Far more undocumented than all PLWH/A say they are uninsured (81%). Relatively few
(13%) report any Medi-Cal or Medicaid coverage.

According to the sample, 81% feels that their physical health is fair or better, and more
undocumented (62%) than all PLWH/A say their physical health has improved since they
first sought treatment. Emotionally, 94% of all undocumented PLWH/A report currently
having fair emotional health or better, and 59% feels it is better now than when they first
sought treatment.

Stage of Infection
The 2004 Care Assessment Survey shows that 43% of undocumented PLWH/A have
been positive for three to eight years, compared to 28% of the general PLWH/A. Only
31% has lived with HIV for more than eight years, compared to 54% of the general
PLWH/A.
Thirty-eight percent (38%) of the undocumented PLWH/A report disabling symptoms,
and 45% have received an AIDS diagnosis.
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Undocumented PLWH/A are slightly less likely to be out of care than other PLWH/A (18%
have stopped seeing a doctor for over a year since diagnosed), and a higher percentage (82%)
reports a regimen of antiretrovirals or protease inhibitors. Compared to other PLWH/A,
undocumented are less likely to skip or end their medication regimen, with 47% reporting
never skipping their medication. The primary reasons for skipping medications are because
they forgot (47%), followed by just not wanting to take them (24%), and side effects (23%).

Co-Morbidities

Undocumented PLWH/A report a higher rates of STDs than all PLWH/A. Twenty-two
percent (22%) report having had genital warts, 19% have had genital herpes, and 15% have
had syphilis in the last two years. Sixteen percent (16%) report having hepatitis A or B.

Substance use is relatively low among undocumented PLWH/A and much lower than among
all PLWH/A. Over half of those who had ever consumed alcohol (73%) consumed alcohol
within the last six months (63%) with 18% drinking once a week or more. Only 7% report
ever injecting substances compared to 15% of the total sample.

A large percentage (64%) of undocumented PLWH/A have received mental health services
since they were diagnosed with HIV. Most of them (75%) have received individual
counseling or therapy with a professional, and 48% have received medication for
psychological or behavioral problems. In the last two years, 47% have received a diagnosis
of depression and 22% have received a diagnosis for anxiety.

Top Service Need

Figure 1-50 shows the top ten service needs for the undocumented PLWH/A who completed
the 2004 Care Assessment Survey, which includes six primary health care services.
Undocumented PLWH/A report higher needs than all PLWH/A, especially in the housing
and food services, which is consistent with their lower income. The top five needs are:
outpatient medical care (96%), benefits case manager (87%), bus passes (85%), drug
payment assistance (80%) and oral healthcare (79%).

Figure 1-50 Top Service Needs for Undocumented PLWH/A
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Barriers

of difficulty they represented for them when trying to access care. Table 1-25 shows the top
five reasons along with the average score indicating the size of the barrier each of the items
represented for them.

On average, more undocumented PLWH/A reported problems in getting services than all
PLWH/A. Four of the top five barriers are individual barriers, and the other is
organizational. The largest problem experienced was not knowing who to ask for help
(65%), and they rated it as a moderate problem. That was followed by 64% not knowing that
a service or treatment was available, as a moderate problem. For those with a problem with
insurance, it is a large barrier.

Table 1-25 Undocumented: Top Barriers to Care
REASON
% with Problem
Average Score
available to me
63.7% 3.1
Not understanding the instructions for obtaining
the service or treatment
58.3% 2.8

Men who have Sex with Men (MSM)

Four hundred and forty (440) MSM, including MSM/IDU, completed the survey. The were
under-sampled to allow sufficient numbers of more difficult to reach populations into the
sample for analysis. When the MSM and MSM/IDU are weighed up to their proporpiton in
the populations they represent 78% of the weighted sample, with a weighted sample size of
570.

Demographic Profile
Forty percent (40%) of MSM describe their racial background as Hispanic, 20% as Black
and 3% as API and other ethnicities. All of them form the MSM of Color category, with
somewhat different needs than the Anglo MSM, which compose over one-third of the
MSMs (37%).
MSM were mostly born in the US (63%), and about a third (29%) are from
Mexico/Central America. This has an impact on the way they access services as 18% of
the total MSM describe their legal status in the United States as undocumented.
The mean age of MSM is 40. Youth (18 to 19 years old) represent only 1% of the total,
those between the ages of 20 and 44 years make up 80% and those 45 years or older
make up 18% of this subpopulation.
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Anglo MSM consistently have a higher level of education with only 9% not completing
high school, compared to over a quarter of MSM of Color (27%). Similarly, over 60% of
MSM of Color, but only 26% of the Anglo MSM, make less than $9,000 a year. Also,
MSM of Color have a higher employment rate with 26% working part or full time as
opposed to 13% of Anglo MSM.
Most of the MSM live in an apartment or house they rent (65%) or own (8%). Their
living situation is mostly safe (92%), habitable (97%) and stable (84%). MSMs are
vulnerable to homelessness with 16% reporting being in transitional housing in the last
two years, 15% reporting being homeless within the same period of time, and 11% in a
homeless shelter.
In the 2004 Care Assessment Project sample, 88% of MSM feel they contracted HIV by
having sex with a man followed by 4% who indicated infection by having sex with a
woman and 2% by sharing needles. Accordingly, 75% of the sample considers
themselves gay, 18% bisexual or on the down-low and 6% heterosexual.
Almost half of MSM of Color (49%) are currently uninsured, and 39% report Medi-Cal
or Medicaid coverage. On the other hand, only 15% of Anglo MSM do not report any
insurance coverage, and Medi-Cal or Medicaid covers the health care needs of 68% of
this population.

Stage of Infection
More than half of MSM have been HIV positive for more than eight years (56%), and
only 7% have been positive for less than a year.
Forty-seven percent (47%) of the MSM of Color and 54% of the Anglo MSM report
disabling symptoms. Likewise, 42% and 60% respectively have received and AIDS
diagnosis.
Forty-three percent (43%) of MSM would say that their physical health is fair, while 47%
say their health is good or excellent. Over half (55%) think it is better now than when
they sought treatment. Emotionally, 44% describe their emotional health as good or
excellent; consistently, 55% feel it has improved since they sought treatment for their
HIV infection.


About a third (31%) of MSM have been out of medical care for six months, and 23% have
stopped seeing a doctor for over a year; the main reason for going back to care is getting
sicker (51%). A high percentage (77%) reports being on antiretrovirals or protease
inhibitors, and about a third is currently on antibiotics (33%). Thirty-seven percent (37%) of
MSM report never skipping or ending their medication regimen, and the main reason for
stopping or skipping their medication is forgetting (61%), followed by side effects (29%).

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Co-Morbidities

MSM have about the same rate of STIs as all PLWH/A with 15% reporting Hepatitis A or B
in the last years, and 17% reporting Hepatitis C. Hepatitis C is much greater among the
MSM/IDUs (35%) than other MSM.

Substance use is higher amongst Anglo MSM than amongst MSM of Color, specifically for
drugs such as crystal meth. Anglo 55% of all Anglo MSM living with HIV and AIDS report
they have used crystal meth compared to just 21% of MSM of color. MSM/IDU account for
the 8% of MSM who report injecting drugs, but MSM as a group are less likely to inject
drugs than all PLWH/A.

Seventy-one percent (71%) of MSM living with HIV and AIDS have accessed mental health
counseling or treatment since diagnosed with HIV, and 48% have received medication for
psychological or behavioral problems. A greater percentage of Anglo MSM report mental
health problems than MSM of color. Sixty-five percent (65%) of Anglo MSM report having
been diagnosed with depression in the last two years and 51% with anxiety. MSM of Color,
on the other hand, report diagnoses of 50% and 33% respectively for these two mental health
problems.

Top Service Need

The following figure shows the top ten service needs for the MSM who completed the 2004
Care Assessment Survey, which includes five primary health care services. MSM of Color
have, overall, the same pattern of needs to Anglo MSM, but their need is slightly greater.
The top five needs are: outpatient medical care (95%), oral healthcare (80%), benefits case
manager (77%), bus passes (72%), and food bank or pantry (68%).

Figure 1-51 Top Service Needs for MSM living with HIV/AIDS

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Barriers

represented for MSM.

The barriers cited by MSM of Color and Anglo MSM tend to be the same. The one big
difference is that 46% of MSM of Color say they a problem with insurance while 28% of the
Anglo MSM say insurance coverage is a problem. Anglo MSM in general find fewer
problems in getting care than MSM of color, and they rate problems they have as less
serious. Both groups feel that not knowing that a service or treatment was available to them
is the biggest barrier, and it was a problem for about half of the MSM. While about a quarter
of the MSM said that eligibility was a problem for them, it was among the biggest barriers
they faced in receiving care.

Table 1-26 MSM: Top Barriers to Care
Reason
% with problem
Average Score
Not knowing that a service or treatment
was available to me
50.6% 2.8
Not knowing a location of the
service(s)
43.5% 2.8
The amount of time I had to wait in a
waiting room
40.4% 2.6

Latinos/as or Hispanics

Because of the oversampling of women, Latinas were oversampled in the survey, and
weighted back to their correct population proportion. Three hundred and twelve 312 Latinos
completed the survey (43%) and, for analysis, were weighted back to 40%.

Demographic Profile
The Latino gender proportion is the same as for all PLWH/A, 87% male and 13% female.
Over two-thirds of Latinos (69%) were born in Mexico/Central America, and 25% in the
United States. Of the 75% born outside the US, over half (51%) are undocumented and
17% have a permanent visa.
The mean age of the Latinos is 37. Eighty-nine percent (89%) of the sample is between
the ages of 20 and 44.
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The majority feel they contracted HIV by having sex with a man (83%), with 61%
identifying themselves as gay. In addition, 13% portray their sexual orientation as
bisexual and 23% heterosexual or straight.
Over a third (40%) has not completed high school, significantly higher than that of other
PLWH/A (25%). Their employment rates are somewhat higher (29% working part time
or full time), but their yearly income is lower than other PLWH/A (50%), with 65% of
the population making less than $9,000 a year.
The living situation of the Latinos is similar to other people living with HIV/AIDS. Over
two-thirds (67%) rents a house or apartment, and the majority feels that their living
condition is safe (85%), habitable (93%) and stable (80%).
A high percentage of the Latinos are currently uninsured (54%) and far fewer Latinos
(35%) report Medi-Cal or Medicaid coverage than all PLWH/A (50%).
Nevertheless, a much lower percentage receives benefits such as long term disability
(13% Latinos versus 23% overall) or SSI (21% Latinos versus 34% of all PLWH/A), and
this could be due to their residency status among other factors.

Latinos are more positive about their physical health than all PLWH/A but rate their
emotional health about the same. When asked about their physical health, 91% of the
Latino sample indicates it is fair, good, or excellent; 26% feel it is better and 36% much
better, as compared to when they first sought treatment. Emotionally, 88% feel their
emotional health is fair, good, or excellent, and 55% feel it has improved since they
sought care for their HIV infection.

Stage of Infection
The length of HIV infection for Latinos has been more than eight years (48%), and 43%
have been told that their infection has progressed to AIDS. Similar to all PLWH/A, 41%
report disabling symptoms.


Latinos appear to be slightly less likely than other PLWH/A to stop seeking care, with only
26% reporting not seeing a doctor for six months since being diagnosed with HIV. Seventy-
eight percent (78%) of Latinos report taking antiretrovirals or protease inhibitors and 28%
report using antibiotics.

Forty percent (40%) of Latinos living with HIV/AIDS have never skipped or stopped their
medication regimen, while 30% report having skipped their medication at least once a month.
The primary reasons for skipping their medications are because they forgot (54%), side
effects (24%) and just not wanting to take them (24%).
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Co-Morbidities

The STD rates among the Latino population do not differ significantly from all PLWH/A.
They have lower rates of hepatitis (all types), and somewhat higher rates of genital herpes
and warts (16% each), and syphilis (11%).

Drug use is low among the Latinos. Only12% report ever injected drugs, and injectable
substances such as crystal meth or heroin have a lower consumption rate (2%) when
compared to other PLWH/A (3.5%).

Latinos report fewer mental health problems than the general population of PLWH/A. They
report half as many diagnoses of bipolar disorder (7%) and also less anxiety cases (29%) than
the general PLWH/A. Depression rates, although, are quite high with more than half (52%)
being diagnosed in the last two years. This may reflect lack of access to mental health
services, or a cultural reluctance to visit mental health providers.

Top Service Need

Figure 1-52 shows the top ten service needs for Latinos living with HIV/AIDS, which
includes six primary health core services. The top two are core medial services, outpatient
medical care (94%), oral healthcare (79%). Third is bus passes (79%). The other top care
services reflect their lack of insurance and ability to find reimbursement for care and include
benefits case manager (78%) and assistance paying for medications (70%). Latinos are also
more likely than all PLWH/A to mention the need for prevention information.

Figure 1-52 Top Service Needs among Latinos

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Barriers

five barriers to accessing care along with the average score indicating the size of the barrier
each of the items represented for them.

On average, more Latinos report problems in getting services than other PLWH/A, and they
give those problems slightly higher difficulty ratings. The two largest problems experienced
were not knowing that a service or treatment was available to them (57%) and they rated it as
a moderate problem. That was followed by 53% not knowing the location of a service, as a
moderate problem. Confirming their lack of insurance, a large percent also mention lack of
insurance coverage and for those without insurance, it is a high barrier to receiving care.

Table 1-27 Latinos: Top Barriers to Care
REASON
% with Problem
Average Score
available to me
56.5% 3.1

Severely Mentally Ill (SMI)

The severely mentally ill are defined as those who are have had medication for a mental
illness or reported being an inpatient for a mental health illness.

Demographic Profile
Slightly less than half (49%) of the sample reported being mental illness. Approximately
1% are under 19 years old, while 77% are between the ages of 20 and 44 and 22% are 45
years or older.
PLWH/A born in the US and Anglo tend to be more likely than all PWLH/A to report
severe mental illness. Latinos tend to be less likely to report mental illness. About three-
quarters (73%) was born in the United States, 22% in Mexico/Central America, 2% in
South America and 1% in Africa. Forty percent (40%) of those with a history of mental
illness describes their racial background as Caucasian or Anglo, 33% as Latino/a and
23% Black. This data suggest the availability of mental health resources and cultural
factors play a large role in the use of these services.
The educational level of the SMI is similar to other PLWH/A with 23% of them not
completing high school (compared to 25% for all PLWH/A).
Predictably, the employment rate for the SMI is twice as low as all PLWH/A with only
4% working full-time compared to 10% of all PLWH/A.
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Like other PLWH/A, most of the SMI (66%) live in an apartment or house they rent, and
6% in an apartment or house they own.
Twenty-eight percent (28%) of SMI are uninsured, a lower percentage than amongst all
PLWH/A (36%), which is consistent with lower reported rates among those who do not
have access to reimbursed mental health services.

SMI living with HIV/AIDS report slightly worse physical health and significantly worse
emotional health. Still 88% of SMI report fair physical health or better , with 53%
indicating that their physical health has improved since they first sought treatment.
Emotionally, their health tends are relatively low with 16% describing it as poor and 47%
fair. However, 55% state that it is better now than when the when they first sought
treatment for their HIV, about the same as all PLWH/A.

Stage of Infection
Severely Mentally Ill PLWH/A report a slightly higher percent of length of HIV infection
at eight years or more (59%) than found among all PLWH/A (54%).
In the 2004 Care Assessment Survey, 53% of the SMI has an AIDS diagnosis, and, more
than half (53%) reports disabling symptoms significantly higher than all PLWH/A.


Most of the SMI (74%) are currently taking antiretrovirals or protease inhibitors, and a third
(33%) reports never skipping their medication, similar to all PLWH/A. The most common
reasons for not taking their medication are forgetting (56%) and side effects (33%). SMI
have not stopped seeing a doctor more than other PLWH/A, only 32% reports being out of
care for six months, and 24% for a whole year.

Co-Morbidities

Severely mentally ill people living with HIV/AIDS report more substance use than all
PLWH/A. Sixty-five percent (65%) have tried marijuana, 55% crack or cocaine and 43%
crystal meth.

STD rates do not deviate significantly from all PLWH/A. Nineteen percent (19%) reporting
Hepatitis C infection (compared to 15% for all PLWH/A) and 14% genital herpes (compared
to 11% for all PLWH/A).

This is a population defined by their mental health issues. Therefore, as expected, the mental
health problems rates are very high, with 83% being diagnosed with depression in the last
two years, 62% with anxiety, and 25% with bipolar disorder. Several report more than one
mental illness.

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Top Service Need

Figure 1-53 shows the top ten service needs for the Severely Mentally Ill living with
HIV/AIDS who completed the 2004 Care Assessment Survey, which includes five primary
health care services. SMI ranking of service needs is very similar to other PLWH/A, but, as
expected, they report a significantly greater need for individual mental health therapy. Group
mental health needs (42%) is higher than all PLWH/A, but not to the same degree as
individual mental health. The top five needs are: outpatient medical care (95%), benefits
case management (81%), dental (79%), individual mental health (78%), and bus passes
(77%).

Figure 1-53 Top Service Needs among Severely Mentally Ill

Barriers

represented for them.

SMI show a slightly higher tendency to report problems in getting services than other
PLWH/A. Four of the top five barriers are individual barriers, and the other is
organizational. The largest problem experienced (54%) was not knowing that a service or
treatment was available, and they rated it as a moderate problem. That was followed by not
knowing the location of a service (50%), too much paperwork or red tape, a problem
experienced by 47% of the SMI, who considered it a small to moderate problem. Although
only a quarter of the SMI said that eligibility was a barrier. For them, however, it was a very
big barrier.

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Table 1-28 Severely Mentally Ill: Top Barriers to Care
REASON
% with Problem
Average Score
Not knowing that a service or treatment was available to
me
53.5% 2.7
My physical health has not allowed me to get to the place
where the service is provided
45.5% 2.6
Not understanding the instructions for obtaining the
service or treatment
45.5% 2.7

Women of Childbearing Age (WCB)

For the purpose of this report, women of childbearing age (WCBA) are women between the
ages of 18 and 49. One hundred and twelve (112) WCBA participated in the survey, and
when weighted back to their proper proportion, WCBA represent just over 10% of all
PLWH/A.

Table 1-29 presents the age, racial/ethnic, risk group, and geographic distribution for WCBA
living with HIV/AIDS. It indicates that:
WCBA living with HIV/AIDS are mostly women of color (83%); Anglo WCBA living
with HIV/AIDS represent about 17% of all WCBA participating in the survey. There are
slightly more Latinas than African American women, although African American
women, who represent a much smaller population in LA, have a higher rate of infection.
IDU transmission accounts for 9% of the cases among WCBA living with HIV/AIDS.
Seventy-four percent (74%) of WCBA accessing care say heterosexual sex was their
likely mode of transmission.

Table 1-29 Women of Childbearing Years (18-49): Demographic Profile
AGE GROUP
18-19 5.3%
20-44 88.1%
45+ 6.6%
RACE/ETHNICITY
African American/Black 37.3%
American Indian or Native American 1.4%
Asian or Asian American 2.1%
Native Hawaiian or other Pacific Islander 1.1%
Anglo/White 16.8%
Latino 40.6%
Other/mixed 0.7%
RISK GROUP
IDU 8.9%
Hetero 73.5%
Other/unknown 2.5%

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Not shown in the table above is:
Thirty-six percent (36%) of WCBA living with HIV/AIDS do not have a high school
education. Thirty-two percent (32%) have received a high school diploma and four
percent (4%) of WCBA living with HIV/AIDS have received a General Equivalency
Degree. Twenty-nine percent (29%) have completed at least one year of college. .
Slightly more WCBA,19%, than all PLWH/A are employed in some capacity, and 21%
WCBA say they are not working but are looking for work. Significantly more WCBA
(49%) are not working and not looking for work.
Based on the 2004 Needs Assessment Survey, 62% of WCBA living with HIV/AIDS
earn less than $9000 a year. Forty-six percent (46%) receive health insurance coverage
through Medical/Medicaid and 6% through Medicare. Thirty-four percent (34%) report
having no health insurance.
Not surprisingly, WCBA living with HIV/AIDS (17%) are less likely than other
PLWH/A (37%) to live alone. Forty-three percent (43%) indicate that they are living
with roommates and 50% say that there are children in their households, as compared to
14% of all PLWH/A.
Seventeen percent (17%) of WCBA living with HIV/AIDS consider their current housing
situation unstable, and about 11% believe it is unsafe. Fourteen percent (14%) of WCBA
living with HIV/AIDS have lived in a drug treatment facility and 19% have lived in a
homeless shelter over the last 2 years.


Significantly more WCBA (62%) than all PLHW/A say that their physical health is good to
excellent , but about the same percent (53%) say they are better now than when they found
out they were infected. Their reported emotional health is the same as for all PLWH/A.

Stage of Infection

Table 1-30 shows the length of HIV infection for WCBA living with HIV/AIDS. The
majority (74%) have been positive for 3 or more years. WCBA living with HIV/AIDS (32%)
are less likely to report and AIDS diagnosis than all PLWH/A (47%), and 32% report they
are experiencing less disabling symptoms from HIV than all other PLWH/A (47%).

Table 1-30 Length of HIV Infection in WCBA
Percent (%)
Less than 1 year 11.2%
1 to 3 years 15.0%
3 to 6 years 28.0%
More than 8 years 45.9%
Total 100%

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According to the 2004 Needs Assessment Survey, almost three-quarters (74%) of WCBA
living with HIV/AIDS reported that they are currently taking antiretrovirals or protease
inhibitors. Thirty-seven percent (37%) report adhering to the schedule prescribed. Forty-
seven percent (47%) report skipping their medication at least once a month and 8% have
abandoned the medications all together. Table 1-31 shows the top five reasons WCBA living
with HIV/AIDS skip taking their medications, where forgetting to take the medications was
number one.

Table 1-31 WBCA: Top Reasons for Skipping Medications
Top Reasons Percent
Forgot 45.1
Side effects 23.5
Just did not want to take them 18.8
My doctor advised me to stop taking the medications 18.1
Ran out of medications 17.8

Co-Morbidities

According to the 2004 Needs Assessment, 7% of WCBA living with HIV/AIDS have had
hepatitis A or B and about 21% have had hepatitis C. Thirty-nine percent (39%) have had
yeast infections; 13% genital herpes; 5% genital warts, 6% Chlamydia; 4% syphilis and 4%
percent have had gonorrhea in the last two years.

Alcohol and marijuana are the most frequently used substances among WCBA living with
HIV/AIDS, where 38% of 67% that have ever used alcohol report alcohol consumption in the
last six months, and 25% of 48% of WCBA that have ever used marijuana report marijuana
usage in the last six months. Of the 12%WCBA who reported ever using heroin, 15% say
that they use it at least once a week.

The 2004 Needs Assessment Survey also reveals that WCBA living with HIV/AIDS are
likely to receive some type of mental health service; 84% have received individual
counseling or therapy, 50% have received group counseling; 22% were inpatient at a hospital
for mental health compared to 70% of all other PLWH/A.

Top Service Needs

Figure 1-54 shows the top service needs for WCBA living with HIV/AIDS in the 2004 Needs
Assessment. WCBA living with HIV/AIDS ranked outpatient medical care as their number
one service need; this was followed by case management services (82%) and dental services
(76%). As expected, WCBA living with HIV/AIDS (72%) reported a higher need than other
PLWH/A (58%) for services from a specialist likely reflecting the ob-gyn needs of women.
WCBA living with HIV/AIDS also reported a higher need than other PLWH/A for individual
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mental health counseling (68%) and food services; food banks (72%) and food vouchers
(65%).

Figure 1-54 Top Service Needs for WCBA

Barriers

Using a five point scale where 1 indicates a very small problem in seeking care and a
5represents a big problem, participants were asked to rate 30 items in terms of the level of
difficulty they experienced when trying to access care. Table 1-32 shows the top five reasons
for not seeking care along with the average scores which indicate the size of the problem.

More than half of the WCBA (52%) felt that their lack of knowledge about a service that was
available to them was their biggest barrier in accessing care; this was followed by their lack
of knowledge about the location of a service (50%), both with average scores of 3.0,
representing moderate problems. Inadequate insurance coverage (36%) and lack of
transportation (36%) with mean scores of 3.5, presented moderate to big problems for
WCBA living with HIV/AIDS. Thirty-eight percent (38%) of WCBA living with HIV/AIDS
reported that their state of mind or mental ability to deal with the treatment was a problem
with a mean score of 2.9 representing a small to moderate problem. For the 13% of women
who say that denial of service due to their criminal history is a barrier, most say it is a big
barrier.

Table 1-32 WCBA: Reasons for Not Seeking Care
REASON % with Problem
Average Score
5=very big 1=very
small
Not knowing that a service or treatment was available to me. 52.0% 3.0
Not knowing a location of the service(s). 50.4% 3.0
My state of mind or mental ability to deal with the treatment. 37.7% 2.9
My lack of, or inadequate, insurance coverage. 36.3% 3.5
No transportation. 35.8% 3.5
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Homeless

Of the 732 people surveyed 31 (4.2%) say they are currently homeless. Currently homeless
is defined as those saying they currently live in a car or other vehicle (12%) or vehicle,
shelter or mission(68%), or outside (20%). Given the small sample size of currently
homeless, the analysis may not be generalizable to all homeless persons living with HIV and
AIDS.

Demographic Profile
Over three quarters of the homeless interviewed live in the Metro SPA. Another 10%
live in the South Bay Long Beach SPA.
The homeless living with HIV and AIDS are disproportionately female. Still 75% of
homeless PLWH/A identified themselves as male and 25% as female.
The homeless living with HIV and AIDS are disproportionately African American, with
36% identified themselves as African American, 32% Anglo, 32% Hispanic/Latino.
The homeless living with HIV and AIDS are less likely to have a high school degree than
all PLWH/A, with 36% reporting no high school education. However 26% received a
high school diploma and 4% of homeless PLWHA completed a General Equivalency
Degree (GED). Thirty-five percent (35 %) have some college education or higher.
Not surprisingly, more homeless living with HIV and AIDS than all PWLH/A say their
living conditions are unsafe (25% homeless and 9% all PLWH/A) Still, three-quarters
(75%) of homeless PLWH/A say that their living condition is safe and 60% say its stable.
In the last 2 years, 16% of homeless PLWH/A have been incarcerated and 14% have
lived in a drug treatment facility.
The homeless living with HIV and AIDS are among the poorest PLWH/A. Seventy-six
percent (76%) of the homeless PLWH/A are earning less than $9000 a year. No
homeless person reported earning more than $18,000.
The vast majority of homeless are not working (98%). Twenty-one percent (21%) are
looking for work.
Forty-two percent (42%) of homeless PLWH/A currently do not have any health
insurance. Forty-seven percent (47%) of homeless PLWH/A say that they are receiving
health insurance coverage through Medical/Medicaid and 27% through Medicare.

Homeless PLWH/A are less healthy than all PLWH/A; 38% of homeless PLWH/A report
their current physical health as good to excellent as compared to 50% of all other
PLWH/A. Twenty-eight percent (28%) of homeless PLWH/A say that their current
physical health is poor as compared to 9% of all other PLWH/A.
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Stage of Infection
According to the 2004 Needs Assessment Survey 8% of homeless PLWHA identified
injection drug usage as the way they contracted HIV. Seventy-nine percent (79%)
believe that they contracted HIV through sex with a man, 11% through sex with a woman
and 1% from a blood transfusion.
The majority of homeless PLWH/A interviewed (83%) have been positive for 3 or more
years, and 6% have been aware of their status for 1 year or less.
Sixty-seven percent (67%) of homeless PLWH/A report disabling symptoms, and 49%
reported that their HIV had progressed to AIDS.


Fewer homeless PLWH/A (65%) are currently taking antiretrovirals or protease inhibitors
when compared to all PLWH/A (76%). Twenty-eight percent (28%) have skipped taking
their medication at least once a month; 12% have stopped taking them all together. The top
five reasons homeless PLWHA gave for skipping their medications were; forgetting to take
them (56%); side-effects (50%); just not wanting to take them (28%); having a difficult
schedule or requirements (24%) and being advised not to take them by a doctor (15%).

Co-Morbidities

In the 2004 Needs Assessment Survey, 19% report having hepatitis A or B in the last year,
while 25% report having hepatitis C in the last year. In the past year, twenty-three percent
(23%) of homeless PLWH/A report genital herpes and 31% report genital warts. About 6%
report syphilis and 20% report Chlamydia. Homeless PLWH/A report high rates (18%) of
gonorrhea, but this may be unreliable due to small sample sizes.

Thirteen percent (13%) of homeless PLWH/A report a history of injection drug use.
Figure 1-55 shows the usage of injectable substances for homeless PLWH/A as compared to
all other PLWH/A, in the last six months. It should be noted that this is a percentage of
PLWH/A and homeless that have reported ever using the substance. According to the figure,
crystal meth is shown to have the highest usage among homeless PLWHA with 53%
reporting that they have used it in the last six months. Heroin (40%) and crack/cocaine
(38%) were also frequently used by homeless PLWH/A over the last six month.

Figure 1-55 Injectable Substance Use in Last Six Months

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Substance abuse and mental illness are co-morbidities reported by homeless. The 2004
Needs Assessment Survey reports that 64% of 70% of homeless PLWH/A who have ever
used alcohol have used alcohol within the last six months, with 20% drinking at least once a
week. Similarly, 55% of the 53% who report ever using marijuana say they have used
marijuana in the last six months, with 27% reporting usage at least once a week.

The homeless PLWH/A report high levels of depression (47%) and anxiety (37%). In
addition, the homeless PLWH/A report higher percentages of bipolar disorder and dementia
than all PLWH/A. Within the last two years, 31% of homeless PLWHA have received a
diagnosis for bipolar disorder as compared to 14% of all other PLWH/A and 25% of
homeless PLWH/A have been diagnosed with dementia as compared to 5% of all PLWH/A.
Forty percent (40%) of homeless PLWH/A have been inpatient for mental health services at
some point as compared to 23% of all other PLWH/A suggesting more severe mental health
conditions among homeless PLWH/A. Three-fourths of the homeless PLWH/A have
received individual counseling or therapy and 55% prescribed medication, but this is less
frequent than all PLWH/A.

Top Service Need

Based on the 2004 Needs Assessment Survey, Figure 1-56 shows the top ten service needs
for homeless PLWH/A which includes two housing services: housing information services
(74%) and independent housing (69%), two transportation services; bus passes (95%) and
taxi vouchers (75%) and two food services; food vouchers (70%) and food banks (69%).
Other top needs include case management (85%), nutritional education (73%) and HIV
prevention information in the doctors office (68%). Outpatient medical care (96%) was the
number one service need among homeless PLWH/A.

Figure 1-56 Top Service Needs for Homeless PLWH/A

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Barriers

for not seeking care along with their average scores which indicate the size of the problem.

The 2004 Needs Assessment Survey reports not knowing the location of a service (56%)
and not knowing that a service was available (55%) were the top two barriers to care for
homeless PLWHA with average scores of 2.8 and 2.9 indicating small to moderate problems.
Not having transportation was a larger barrier for homeless PLWHA (53%) than all other
PLWH/A (29%) and was reported as a small to moderate problem (average score = 2.4). Not
surprisingly, 46% of homeless PLWH/A reported that a lack of or inadequate insurance was
a moderate to big problem for them with a mean score of 3.4. Almost half (49%) of
homeless PLWH/A reported that their state of mind or mental ability to deal with the
treatment was a small to moderate problem (average score =2.2) for them in accessing care.

Table 1-33 Homeless: Top Barriers to Care
REASON % with Problem
Average Score
Not knowing the location of a service 56.1 2.8
Not knowing that a service or treatment was available to me 55.2 2.9
No transportation 52.9 2.4
My state of mind or mental ability to deal with the treatment 48.6 2.1
My lack of, or inadequate, insurance coverage 46.2 3.4

Youth

Sixteen youth completed a survey, and youth, defined as 18 to 24 year old, represent 2.2% of
the weighted sample. Because of the small sample size, the findings for youth may not
represent all youth living with HIV and AIDS.

Demographics
The majority of youths living with HIV/AIDS live in the Metro SPA (32%) and the South
Bay-LB SPA (28%).
Youth participant were more female than all PLWH/A; 78% identify themselves as male
and 22% as female. Nearly 80% of youth surveyed were Latinos (56%) and Anglo (32%)
suggesting that Latino youth are under-represented.
Over a third of the youth identify as heterosexual significantly more than all PLWH/A.
The youth represented in the sample are in the lower socio-economic bracket. Two-thirds
(68%) had less than a high school education and 80% earned less than $9,000 annually.
Two-thirds of the youth surveyed lived independently in an apartment or house. Twenty-
two percent (22%) live with family members. Fifteen percent (15%) of youths surveyed
lived in a homeless shelter over the last 2 years.
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Of all youths living with HIV/AIDS surveyed, 19% are working in some capacity and
18% are not working but are looking for work.
The youth are more likely to have insurance, with 45% saying they receive health
insurance coverage through Medical/Medicaid. Similarly, 45% of youth living with
HIV/AIDS do not have any health insurance.


More youth than all PLWH/A rate their physical health as good to excellent health. However
they are less likely to say their health has improved since they were infected. They rate their
current emotional health about the same as all PLWH/A, but are much less likely to say it has
improved since they found out their status.

Stage of Infection

The youth surveyed are a combination of those infected from birth and those recently
infected. Nearly thirty percent (29%) have been positive for less than a year; 21% for one to
three years, 32% for three to eight years, and 18% have been living with HIV for more than
eight years. Almost half (47%) of youths in the sample have been told that their HIV has
progressed to AIDS, with 94% reporting having an AIDS diagnosis for less than one year.


Less youths living with HIV/AIDS (66%) report taking antiretrovirals or protease inhibitors
than to all other PLWH/A (76%). However, youth living with HIV//AIDS report stronger
adherence to their medications (51%) than all PLWH/A (36%). Further, only 26% of youths
living with HIV/AIDS have skipped taking their medication at least once a month as
compared to 46% of other PLWH/A.

The number one reason youths living with HIV/AIDS gave for skipping their medications
was forgetting to take them(73%). Twenty-two percent (22%) said that they skipped their
medications because they just did not want to take them, 18% said their doctor advised them
to stop taking the medications, 12% indicated a difficult schedule and 5% said they could not
afford them.

Co-Morbidities

Thirty-seven percent (37%) of youths living with HIV/AIDS surveyed have had hepatitis A
or B, and only 1.3% report hepatitis C in the last two years.

Youth are more likely to use drugs than all PLWH/A. Marijuana (79%) was the most
frequently continued use substance among youths living with HIV/AIDS in the last 6
months; frequent use of ecstasy (74%) and alcohol (68%) were also reported over this period.
Seventeen percent (17%) of youths reported a history of injection drug use.

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Top Service Need

Figure 1-57 shows the top ten service needs for youths living with HIV/AIDS. Outpatient
medical care (100%) and case management services (93%) were the top two service needs
for youths living with HIV/AIDS. Four transportation services: bus passes (77%), van
transportation (64%), taxi vouchers (62%) and bus tokens (61%) were also included. Other
services in demand by youths living with HIV/AIDS are the HIV LA directory (69%), food
banks (60%), adherence support from a medical person (59%) and assistance obtaining and
paying for HIV/AIDS related medications (59%).

Figure 1-57 Top Service Needs for Youths living with HIV/AIDS

Barriers

for not seeking care along with the average scores which indicate the size of the problem.

The 2004 Needs Assessment Survey reports that the number one barrier to care for youths
living with HIV/AIDS (55%) is fear of their HIV or AIDS status being found out by others
with an average score of 3.4 indicating a moderate to big problem for this group. Lack of
knowledge about a service that is available (53%) or lack of knowledge about the location of
a service (53%) were equally moderate barriers to care for youths living with HIV or AIDS
(mean scores = 3.0). Other barriers to care reported by youths living with HIV or AIDS in
the 2004 Needs Assessment Survey were lack of, or inadequate insurance coverage (53%)
and not being able to prove eligibility for the service (45%) with mean scores of 3.1 and 3.3
respectively, representing a moderate to big problem.

About a third of the youth said they had a problem with the lack of experience of their
provider and their lack of ability to pay for services. For these youth, however, these
problems were big barriers to receiving care.

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Table 1-34 Youths: Reasons for Not Seeking Care
REASONS % with Problem
Average Score
5=very big 1=very
small
Fear of my HIV or AIDS status being found out
by others - lack of confidentiality
55.1% 3.4
available to me
53.3% 3.0
My lack of or inadequate, insurance coverage. 52.7% 3.1
Could not prove eligibility for the service. 44.5% 3.3

2-1
2. WHERE ARE WE GOING?

GOAL AND OBJECTIVES

This section reviews the goals established in the 2002 Comprehensive Plan and establishes
new service, planning, and infrastructure goals through 2008. This section will not present a
comprehensive list of objectives. The Title I application for year 15 presented a
comprehensive set of goals related to an implementation plan for Core Services and that is
shown in Attachment 16. Rather this plan highlights goals and objectives that can be
accomplished by the Commission and OAPP to build a stronger infrastructure and better
deliver care services.

Overall Goals

The overall goals for the Continuum of HIV/AIDS Care remain the same:
Decreasing HIV/AIDS mortality and morbidity.
Improving the quality and availability of comprehensive HIV/AIDS-related services to
needy individuals and families.
Collaborating with other HIV/AIDS service organizations to assess and identify emerging
HIV/AIDS services delivery needs.
Facilitating a coordinated and community-based viable regional voice for HIV-impacted
populations.

Progress Since 2002

In the 2002 Comprehensive Plan documented an ambitious agenda for sustaining and
improving services for PLWH/A, even as the public health system in Los Angeles County is
facing a fiscal crisis that will reduce publicly funded health care services. Overall, by
emphasizing partnerships, collaborations and linkages, the continuum of care aims for every
client to have equal access to the primary health care core services. Table 2-1 highlights the
activities noted in the 2002 Plan and briefly discusses accomplishments. A more detailed
discussion of accomplishments follow the table.

Table 2-1 2002 Goals and Accomplishments
2002 Comprehensive Care Goals Accomplishments (see below for details)
1. Within the next three years there is a
commitment by the Office of AIDS Programs
and Policy (OAPP), the Commission on HIV
Health Services (CHHS), and the Prevention
Planning Committee (PPC) to move toward
an integrated prevention and care services
continuum of service, and using a web-
enabled data collection and tracking system
to support that effort.
After considerable discussion, the merging of
the Commission and CPG was decided
against. However, there have been a number
of initiatives to better integrate prevention and
care including: 1) tracking of the newly
diagnosed, 2) OAPP contracts include
compensation for the costs of linked referral,
and 3) the data provided by HIV Epi for
behavioral risk groups (BRGs) is coordinated
with the epi data use for care. These are
discussed in greater detail below.
2-2
2002 Comprehensive Care Goals Accomplishments (see below for details)
2. HIV reporting and the active follow-up of
those testing HIV positive is likely to
significantly reduce the number of PLWH
who are not in care and allow better
coordinated care for individuals in the
system.
Tracking newly diagnosed will be achieved
through the implementation of the HIV/AIDS
Interface Technology System (HITS) which has
been in development since 2002. When
implemented it will provide newly diagnosed
PLWH with direct access and entry into
medical outpatient care at the HIV counseling
and testing (HCT) entry point.
3. With the implementation of HIV reporting
statewide, the Los Angeles Countys HIV
Epidemiology Program will be able to more
accurately track and describe the epidemic.
Once a person tested HIV positive, a system
will be implemented to encourage those in
care to seek care and stay in care.
HIV reporting was implemented in California in
July 2002, and HIV data can be considered
reliable and complete no earlier than July
2005.
4. Further development and implementation of
standards of care, quality assurance,
outcomes and indicators for services will
increasingly play an integral role in the
monitoring process.
Continuous quality improvement processes will
be implemented to ensure ongoing updates to
standards, outcomes and indicators and to
achieve best practices in HIV service delivery.
5. The Commission will separate from OAPP
oversight, and, in so doing, will engage its
own professional support staff to carry out
its responsibilities.
The move of the Commission from OAPP in
the Department of Health Services to the
Board of Supervisors was achieved in 2004.
The new Executive Director and professional
staff of the Commission bring a dedicated level
of service to the volunteer Commissioners.
6. The Commission will undertake a more
comprehensive ongoing needs assessment
process by adopting a continuous data
collection model that utilizes ongoing data
collection tools, as well as specialized needs
assessment studies where data is lacking
and further research needed.
The Commission has implemented the
HIV/AIDS Care Assessment Project (H-CAP)
that provides input from PLWH/A into the
planning process.
7. Service planning will be done at the SPA
and potentially at the sub-SPA
neighborhood level in order to reflect the
different needs of communities throughout
Los Angeles County. Service Provider
Networks (SPN)see Attachment 6--and the
Coordinated Prevention Networks (CPNs)
(as described in the Prevention HIV
Prevention Cooperative Agreement for
2002) will lead these efforts with support
from OAPP and the Commission.
The SPNs have been initiated in each of the 8
SPAs. The SPNs bring together many service
providers, both Ryan White CARE Act funded
and not, within the SPA to promote
collaboration networking and partnership in
HIV service delivery.

In addition to the accomplishments in meeting the goals noted in the 2002 Comprehensive
Plan, several specific programs and activities were started between 2002 and 2005 which
improved the outcomes for the Continuum of HIV/AIDS Care and plan for the delivery of
services that conform to practices dictated by a primary health care core.

2-3
Service Achievements

Changing Demographics of the Epidemic

New medical outpatient clinics were opened within the San Gabriel, East, and South Bay/
Long Beach SPAs (3, 7 and 8) providing more geographic coverage for PLWH/A seeking
care and treatment. The new sites in the San Gabriel and East SPAs were opened to serve
heavily populated Latino regions.

Responding to the Service Needs and Gaps of PLWH/A

PLWH/A reported a high need for several services in the 2002 Needs Assessment. The
following changes in Continuum of HIV/AIDS Care were made to meet the needs, fill
service gaps, or respond to barriers identified by PLWH/A.
Oral health was funded in each of the eight SPAs. In addition, a mobile dental van was
implemented to provide more accessible oral health services in Antelope Valley, San
Fernando, San Gabriel, Metro, East, and South Bay / Long Beach SPAs (1, 2, 3, 4, 7 and
8). This effort ensures that PLWH/A, especially those of low-income who live in areas
without HIV-specific dental services, have easier access to dental care.
Food banks for PLWA/H were initiated in each of the eight SPAs.
Nutritional counseling was implemented within all HIV medical outpatient settings.
Client advocacy was implemented as a new service category in response to identified
consumer barriers related to navigating the HIV service delivery system. This service
provides consumer guides, resource directories, a website and informational supplements
to help clients advocate for their health care needs.

Some services were not needed by a large majority of PLWH/A, but were greatly needed by
a smaller subpopulation, such as childcare for PLWH/A with children or translation and
interpretation services for Latinos. The following changes were made in the Continuum in
response to specific needs of subpopulations.
Administrative oversight of HIV childcare services have been centralized within one
agency that subcontracts with licensed childcare providers throughout Los Angeles
County. Thus, these services are easily accessible in each of the eight SPAs. In order to
assure that the services are used to facilitate care visits, Ryan White CARE Act funded
child care has been approved only for persons who need childcare to facilitate accessing
care services.
Peer support and translation/interpretation services have been restructured to include a
training/certification program that ensures providers of such services have the same
knowledge base and skills set to most effectively and appropriately meet the needs of
clients.
The Commission has directed and OAPP has included a contractual obligation that all
Ryan White CARE Act HIV service providers in Los Angeles County have bilingual
staff who provide services in the primary language (s) of the majority of their clientele.

2-4
To better monitor and administer services, the Continuum is moving to a reimbursement
model based on unit costs. While one goal is cost-effective delivery of services, and equally
important goal is the continued high quality of care.
In preparation for adopting unit costs, rate studies were completed for substance use
services and residential services. For these services fee-for-service reimbursement rate
structure was standardized for all providers.
OAPP conducted annual program reviews on 100% of their HIV care and treatment
contracts.

Planning Accomplishments

There are two very significant structural changes that improve the planning process of the
Commission in prioritizing and allocating funds for the Continuum of HIV/AIDS Care.
1. The Commission separated from the oversight of the administrative agency, OAPP.
Commission staff is now responsible for support and oversight of all Commission
activities, committees and subcommittees, collaborations with OAPP, and other Ryan
White CARE Act Titles funded grantees. This new arrangement reduces any conflicts of
interest between the Commission and administrative activities. With a larger number of
dedicated staff, it is expected that the quality of the Commissions work will continue to
improve and decision-making regarding HIV care planning will become increasingly data
based.
2. The membership of the Commission has been restructured to shift from service category
representation to geographic representation. Each SPN within the eight SPAs
recommend provider and consumer representatives for Commission membership. In
addition to addressing the concern of conflict of interest up-front, this methodology
promotes a community planning focus to better facilitate meeting the needs of clients
within the continuum of care in Los Angeles County.

Input Into the Planning Process

The Commission has formalized several aspects of the planning process and increased the
amount and quality of data used for planning and the service priority and allocation process
and the development of standards of care and outcomes for the Continuum of HIV/AIDS
Care. The formalization of the planning process has been discussed earlier in PRIORITY
AND ALLOCATIONS section on page 1-8. In addition:
The input of PLWH/A has expanded through the implementation of the HIV/AIDS Care
Assessment Project (H-CAP). This project includes a yearly survey and focus groups
among a randomly selected panel of PLWH/A. For more information on H-CAP see the
earlier discussion under Methodology, page, xxxix.
Providers have expanded input though a 2005 provider survey administered which was
part of the Assessment of the Administrative Mechanism and by a Commission
administered provider survey.
Providers also have input through the Los Angeles County, Service Provider Networks
(SPNs) that operate in each SPA. The SPNs bring together many service providers, both
2-5
Ryan White CARE Act funded and not, within geographic regions to promote
collaboration, networking and partnership in HIV service delivery. Each SPN
recommends provider and consumer representatives for the Commissioners. The
Coordinated Prevention Networks continue to organize but have yet to realize their full
potential as partners with the SPN at the SPA level.
Providers utilizing CARE Act funds further provide input through a Cross Title
Collaboration Workgroup began in 2004. This group includes grantees of Titles I, II, III,
IV and F. Participants will be working towards coordinated data collection, quality
management indicators, consumer and provider needs assessments and other endeavors
as identified by the group.
The Commission has completed a Financial Needs Assessment in 2003 that provides an
overview of how CARE Act Title I, II, and MAI funds fit into the overall funding of the
Continuum, and it suggests several ways to increase non-CARE Act funding for services
in the continuum of care.
In the prioritization and allocation process the Planning and Prioritization Subcommittee
is better able to make data-based decisions utilizing the Service Category Summary
Sheets (SCSS) developed in late 2004. These provide a synthesis of epidemiological, H-
CAP quantitative and qualitative data, and client tracking system data. The SCSS is more
fully described under the PRIORITY AND ALLOCATIONS section on page 1-8.
The Commission has tracked the recommendations of the Assessment of the
Administrative Mechanism completed in 2002, prioritizing recommendations (see
Attachment 14). The Commission is currently (January 2005) completing the 2004
Assessment of the Administrative Mechanism that identifies several areas for
improvements in the procurement, management, and monitoring of CARE Act funded
constricts.

Infrastructure Development Accomplishments

A System Wide goal in the 2002 Plan was better coordination of care in order to:
1. Reduce the proportion of LAC residents who test HIV positive, but do not return for their
results.
2. Mitigate the delays between testing HIV positive and entering an HIV system of care.
3. Improve local ability to appropriately screen clients for service eligibility, therein
maximizing of Federal resources of last resort.

The first objective was the implementation of technology improvements, and several of the
objectives have been meet.
HIV Interface Technology Systems (HITS) is an IT interface that provides newly-
diagnosed HIV-positive clients with direct access and entry into medical outpatient care
at the HIV counseling and testing (HCT) entry point. The seamless linkage from
prevention to care is supported with the implementation of HITS, funded in part by a
SPNS grant. This is achieved through linking prevention and care data systems,
increasing interface-enabled follow-up by HCT counselors, and individualizing referrals
2-6
to meet clients particular needs. HITS has been in development since 2002, and full
implementation is planned for 2005.
In 2004, OAPP initiated the Casewatch Centralization Project to begin the process of
integrating and collapsing databases into one central data management system and to
begin ensuring consistency of reporting across agencies. This project will be critical in
planning, developing, and evaluating services to the needs of populations per SPA.
HIV reporting was implemented in California in July 2002, but HIV data cannot be
considered reliable and complete earlier than July 2005. The HIV reporting system
improved the Los Angeles Countys HIV Epidemiology Program ability to better track
the epidemic. Questions remain about the efficiency and comprehensiveness of the code-
based system, and the Commission endorses a name-based HIV reporting system to
further enhance knowledge of disease trends and improve regional surveillance cost-
effectiveness while maintaining privacy and identity safeguards and protection.

Objectives through 2008

Several initiatives that will improve the outcomes of the Continuum of HIV/AIDS Care are
planned for the next three years. The move to unit cost reimbursement and adoption of
service standards and quality management indicators will move the service delivery system
to a new plateau of accountability and it will look more like a managed care system.

In 2004-2005 a number of new service awards will be made through the RFP process, which
will result in some new providers. They will need to be brought up to speed in the
administration of their services. Based on the Assessment of the Administrative Mechanism,
an area of potential delay in services is between award and the starting of service delivery.

Existing providers that compete successfully to continue providing services or provide new
services will be working under new contracts and new systems. The impact of different
reimbursement rules and the necessity to adopt and measure standards are areas that should
be allocated sufficient resources to assist providers make the necessary changes.

The rate review studies will allow a more complete understanding of the services offered and
the cost of providing those services. The funding of HIV/AIDS care services will become
more like a managed care system. To avoiding the pitfalls of focusing largely on cost
savings, additional emphasis must be placed on adopting and enforcing standards of care and
ensuring the delivery of high quality services. Monitoring procedures and timeliness and
quality management are two areas that will need improvement if they are to have a positive
impact on the Continuum of HIV/AIDS Care Services.

Not atypical, but nevertheless disappointing, is the continued mediocre integration and
coordination of client tracking software. Experience with HITS and Casewatch/IMACS
demonstrates the difficulty in the development and diffusion of client tracking technology.
Conceptually providers may wish to have a more efficient tracking system of their clients and
participate in sharing information to cut red-tape and check on eligibility, but in reality they
are often resistant to sharing client information or making client transfer to another agency
2-7
easy. The new cost reimbursement system is likely to increase this resistance for lower
acuity clients, while encouraging movement of high acuity (and high cost) patients. While
technical problems will be significant, if history is a good predictor, a substantial level of
resources will have to be budgeted for the implementation and training of the system as well
as ongoing support.

For these reasons, the 2005 Comprehensive Plan has a more modest set of objectives than
those in the 2002 Plan. In this period of change, if the most important objectives are fulfilled
the system will be significantly improved.

In the following sections service goals and objectives are divided by those relating directly to
service delivery, those related to planning, and those promoting the infrastructure needed to
improve the Continuum of HIV/AIDS Care. There are fifteen goals presented in the
following section. The goals of the system are represented by 1 15, and the objectives are
listed under each goal.

Service Delivery Goals

1. Disseminating the Continuum of Care to PLWH/A and consumers to increase
knowledge about the prioritization of services and their availability.
1.1. To promote community planning at all levels, starting in 2005 the Commission
will implement comprehensive training and leadership development activities for
both HIV Commissioners and consumers of care will be initiated. These
activities will provide a mechanism to develop and encourage informed and
educated consumer input as a means to strengthen the Commission structure and
enhance the HIV service delivery system.
1.2. A description of the Continuum of HIV/AIDS care will accompany every RFP as
part of the background package.
1.3. Through the SPNs the Commission will promote partnerships, co-location of
services and formal systems for linkages and referrals.
2.1. Early intervention program providers will use a common client tracking system to
coordinate early care with continuing care. EIS and Title III Early Intervention
Programs will be integrated into the overall Continuum of Care.
2.2. In 2005 through 2008 the Commission will promote awareness and early
treatment through social marketing campaigns targeted toward those living with
HIV who are unaware of their status. Social marketing campaigns will be
targeted within those communities most at risk through the use of small media
and social networks.
3.1. Case Managers and intake personnel will administer standard intake forms that
include eligibility and acuity. Data is to be directly entered or transferred into the
client tracking and case management system.
2-8
4.1. The Commission will use public hearings and develop relations with the media to
promote public understanding and awareness of the HIV epidemic in LAC.
4.2. The Commission will sponsor educational events and coordinate World AIDS
Day seminars and activities with a goal of increasing public understanding and
encouraging personal risk assessments.
5.1. Between 2004 and 2006 all services will be re-bid using an RFP process.
5.2. The Commission and OAPP will conduct workshops and hold information
sessions with providers working with targeted consumers to encourage them to
complete RFPs to deliver CARE Act funded services.
5.3. In 2007, once providers are established, encourage them to mentor specialized
providers serving target populations and to subcontract specialized services.
6. Standards and outcomes will be established for every service category and written into
contract language by OAPP.
6.1. Starting in 2005 continuous quality improvement processes will be implemented
to ensure ongoing updates to standards, outcomes and indicators and to achieve
best practices in HIV service delivery. The Commission will establish, as needed
subcommittees and workgroups to regularly evaluate the effectiveness of certain
aspects of the HIV service delivery system in relation to the current epidemic and
the needs of consumers.
6.2. By 2006, system-wide standards indicators for measuring outcomes will be
completed for all service categories. Outcomes are used to determine, over time,
provider performance based on a set of validated indicators. Currently there are a
set of core service program indicators (see Attachment 15). The Commission and
OAPP will assure that these indicators are related to the health status and quality
of life of PLWH/A. Measurement tools and training will be given to providers to
assess their program relevance and to improve the health and quality of life of
their clients.
6.3. In 2005 The Commission will confirm that service categories and delivery of
services are in accordance with the continuum of care and establish standards of
care for each service.
6.4. In 2005 Technical assistance will be made available to providers for establishing
system-wide standards and measuring outcomes.
7. By 2007 unit costs and cost reimbursement will be in place for all CARE funded
services.
7.1. OAPP will continue to contract rate studies and establish cost reimbursement
schedules for services. OAPP will establish a cost reimbursement for all services
by the end 2007.
7.2. OAPP will provide the commission utilization and demand data to assist the P&P
in prioritizing and allocating funding to services.
2-9
8.1. In 2005, based on the 2004 Assessment of the Administrative Mechanism, the
Finance Committee of the Commission will develop benchmarks for timeliness,
clarity of information, availability, and relationships among partners who procure,
manage, and assess CARE Act funded services.

Planning Goals and Objectives

9. Develop a Los Angeles County Continuum of HIV Services that will incorporate care
and prevention services to allow a seamless integration of detection, early intervention,
and sustained care.
9.1. From 2005-2007 the Commission, OAPP and the PPC will work toward
consolidating strategic plans and continue integrating prevention and care services
into a Continuum of HIV/AIDS Services that include both prevention and care.
10. Epidemiological, consumer, and patient data will be used to plan for the best
combination of services and used to allocate funds to services.
10.1. In 2005 the Commission will continue to support enhanced knowledge of disease
trends and improve regional surveillance and cost efficiency through the adoption
of a name-based HIV reporting system that maintains privacy and identity
safeguards and protection of people diagnosed as HIV positive. It will replace the
current statewide code-based HIV reporting system that was implemented three
years ago.
10.2. In 2005, 2006, and 2007 the Commission will continue to support the HIV/AIDS
Care Assessment Project (H-CAP) to collect consumer data on their service
needs, gaps, and barriers.
10.3. The Commission will continue to pursue and actively participate in research
endeavors that assist in planning activities and/or hones in on best practices and/or
new innovative methodologies that significantly improves the health outcomes of
PLWH/A.
11.1. In 2005 The Commission will work with African American, Latino, API, and
other communities of color to determine the most effective use of Minority AIDS
Initiative (MAI) funds.
11.2. In 2005 The Commission will create a subcommittee to work with the American
Indian Tribal Council to encourage the dissemination of culturally appropriate
messages to bring HIV positive American Indians into care.
11.3. In 2005 the Commission will work with young gay men and disseminate
culturally appropriate material regarding crystal meth use, early detection, and
early treatment for those testing positive.
11.4. The Commission will sponsor a task force to define and meet the needs of the
transgender community.
2-10
12.1. The Commission will develop a set of seminars for new Commissioners on the
use of data for planning and decision making.
12.2. The Commission will debrief with Commissioners on their use and understanding
of data.

Infrastructure Goals
13. Shared information on clients to reduce red tape, facilitate access to services, determine
eligibility, and the health status of patients.
13.1. Continuing in 2005, OAPP will continue the development and implementation of
a real-time web-enabled integrated client database. This system will be enhanced
with the capacity to have shared record management. With proper confidentiality
procedures in place, intake will be centralized and all providers will have access
to the same client information. This enhancement will expedite clients access
into care and will reduce and service redundancy, and check for eligibility for
CARE Act funded services as well as Medi-Cal, Medicare, and other
reimbursement sources.
13.2. Continuing in 2005, OAPP will implement HITS and coordination prevention,
HCT and early treatment and care services to encourage persons who test positive
to seek services.
13.3. Develop case management modules to measure acuity levels.
13.4. Develop automated referrals and automatic scheduling and e-mails.
14. Identify alternate sources of funding to enhance local HIV service delivery systems.
14.1. Partners within the EMA will continue to identify alternative sources of funding
for care services.
15.1. Continuing in 2005, the Commission will implement strategies to improve
measures and enhance consumer satisfaction through such methods as Patient Bill
of Rights and Grievance Procedures.

3-1
3. HOW WILL WE MONITOR OUR PROGRESS AND RESULTS

The various objectives and tasks can be monitored using a variety of methods. For
contracted work, existence of RFPs, disbursement of funds in timely manner, and product
(reports, systems, guides) and events (trainings, meetings, seminars, etc) can be tracked. For
services, numbers of clients can be tracked as well as outcomes, satisfaction, need and unmet
need. Examples are provided below for several of the objectives in the previous section.

SERVICE DELIVERY GOALS AND OBJECTIVES

1. Disseminating the Continuum of Care to PLWH/A and consumers to increase knowledge
about the prioritization of services and their availability.
Objective/Task Monitoring Indicators Outcome
1.1. To promote community planning
at all levels, starting in 2005 the
Commission will implement
comprehensive training and
leadership development activities
for both HIV Commissioners and
consumers of care will be
initiated. These activities will
provide a mechanism to develop
and encourage informed and
educated consumer input as a
means to strengthen the
Commission structure and enhance
the HIV service delivery system.
Written curriculum
Schedule of trainings.
Suggestion tracking
form.
Evaluation of training.
Attendance at trainings.
Trainings held.
List of suggestions.
Results of evaluation.
1.2. A description of the Continuum of
HIV/AIDS care will accompany
every RFP as part of the
background package.
Written description
accepted by OAPP
department of contracts
as attachment to all
RFPs.
Aware of Continuum in
responses to RFPs.
1.3. Through the SPNs the
Commission will promote
partnerships, co-location of
services and formal systems for
linkages and referrals.
SPN meeting minutes
SPN requests /
directives for co-
location of services.
MOUs between SPN
service providers.
Greater accessibility to
services.

3-2
2.1. Early intervention program
providers will use a common client
tracking system to coordinate early
care with continuing care. EIS and
Title III Early Intervention
Programs will be integrated into
the overall Continuum of Care.
Use of CaseWatch by all
EIS and Care Providers
with common client IDs.
Shared client database
between EIS and other
care programs.
Ability to track clients
through the care
system.
2.2. In 2005 through 2008 the
Commission will promote
awareness and early treatment
through social marketing
campaigns targeted toward those
living with HIV who are unaware
of their status. Social marketing
campaigns will be targeted within
those communities most at risk
through the use of small media and
social networks.
Social marketing
discussion in
Commission minutes.
Identification and listing
of communities most at
risk
Contract for social
marketing campaign.
Availability of social
marketing materials.
Social marketing
campaigns in selected
high-risk communities.
Increase in persons who
were out of care
engaging or re-
engaging medical care
in areas where social
marketing campaigns
were implemented.

3.1. Case Managers and intake
personnel will administer standard
intake forms that include
eligibility and acuity. Data is to be
directly entered or transferred into
the client tracking and case
management system.
Contract monitoring of
implementation of
standard intake.
Acuity scales available
for clients.
Knowledge of eligibility
by CMs.
Standard intake form
used by all providers.
Acuity scale algorithm
and program.
Eligibility program
Standized data elements
in client database.

4.1. The Commission will use public
hearings and develop relations with
the media to promote public
understanding and awareness of
the HIV epidemic in LAC.
Commission media
distribution list.
Schedule of public
hearings.
Increaed number of
articles discrimination
and HIV/AIDS in LAC
media.
3-3
4.2. The Commission will sponsor
educational events and coordinate
World AIDS Day seminars and
activities with a goal of increasing
public understanding and
encouraging personal risk
assessments.
World AIDS day
committee.
Agreements / contract
with moderator for
seminars at World AIDS
Day events.
List of events for World
AID Day.
Letters / editorial
supporting HIV/AIDS
Care.
Increased testing in
January 2006.

5.1 Between 2004 and 2006 all services
will be rebid using an RFP process.
Timeliness of RFP
relesases.
Signed contracts for
services awared
through bidding.
5.2 The Commission and OAPP will
conduct workshops and hold
information sessions with providers
working with targeted consumers to
encourage them to complete RFPs
to deliver CARE Act funded
services.
Schedule of workshops.
Promotion of
workshops.
Workshops held.
RFPs submitted by
some attendees of
workshops and
information sessions.
5.3. In 2007, once providers are
established, encourage them to
mentor specialized providers
serving target populations and to
subcontract specialized services.
List of specialized
providers selected for
mentoring.
Mentoring reports.
Mentored providers
submit RFPs.

6. Standards and outcomes will be established for every service category and written into
contract language by OAPP.
6.1 Starting in 2005 continuous quality
improvement processes will be
implemented to ensure ongoing
updates to standards, outcomes, and
indicators and to achieve best
practices in HIV service delivery.
The Commission will establish, as
needed subcommittees and
workgroups to regularly evaluate
the effectiveness of certain aspects
of the HIV service delivery system
in relation to the current epidemic
and the needs of consumers.
Standard Committee
adopts CQI model.
Evaluations of
effectiveness of
standards.
Services meet standards
of care established by
Commission and
OAPP.
3-4
6.2. By 2006, system-wide standards
indicators for measuring outcomes
will be completed for all service
categories. Outcomes are used to
determine, over time, provider
performance based on a set of
validated indicators. Currently
there are a set of core service
program indicators (see Attachment
15). The Commission and OAPP
will assure that these indicators are
related to the health status and
quality of life of PLWH/A.
Measurement tools and training will
be given to providers to assess their
program relevance and to improve
the health and quality of life of their
clients.
Written standards for
each Care service.
Commission and OAPP
adopt outcomes for each
service.
Study commissioned to
assess relationship
between outcome and
quality of service.
Trainings scheduled for
providers on CQI.

Services provided with
the same quality and
effectiveness by all
providers.
All providers adopt
standards and
outcomes.
All providers use
standards and measure
outcomes in uniform
manner.
6.3. In 2005 The Commission will
confirm that service categories and
delivery of services are in
accordance with the continuum of
care and establish standards of care
for each service.
OAPP will include in
annual audit an
assessment that CARE
Act funded services are
those in the Continuum
of Care and they meet
the standards for the
services offered.
All Providers receive
an assessment of
services and how they
meet their standards. If
improvement is needed
it is included in POCA.
6.4. In 2005 Technical assistance will
be made available to providers for
establishing system-wide standards
and measuring outcomes.
Schedule of TA on
standards and outcomes.
Evaluation of TA
completed.

Provider attend TA.
Providers understand
standards and
outcomes.

7. By 2007 unit costs and cost reimbursement will be in place for all CARE funded services.
7.1. OAPP will continue to contract
rate studies and establish cost
reimbursement schedules for
services. OAPP will establish a
cost reimbursement for all
services by the end 2007.
Rate studies
commissioned.
Cost reimbursement plan
implemented.
Rates for each service.
Contracts for services
reflect expected units
provided and cost per
unit.
3-5
7.2. OAPP will provide the
commission utilization and
demand data to assist the P&P in
prioritizing and allocating funding
to services.
Commission receives
utilization data and
demand data on a timely
basis.
Part of the priorityies
and allocation process
takes into account the
utilization and demand
data.

8.1. In 2005, based on the 2004
Assessment of the Administrative
Mechanism, the Finance
Committee of the Commission
will develop benchmarks for
timeliness, clarity of information,
availability, and relationships
among partners who procure,
manage, and assess CARE Amct
funded services.
Standards committee
recommends benchmarks.
Commission adopts
benchmarks for
timeliness, clarity,
availability, and
relationships for the
procurement,
administration, and
assessment of services.
Benchmarks assessed in
each Assessment of the
Administrative
Mechansim.
OAPP and providers
aware of benchmarks.
Benchmarks trended in
Assessment of
Administrative
Mechanism.

PLANNING GOALS AND OBJECTIVES

9. Develop a Los Angeles County Continuum of HIV Services that will incorporate care and
prevention services to allow a seamless integration of detection, early intervention, and
sustained care.
9.1. From 2005-2007 the Commission,
OAPP and the PPC will work
toward consolidating strategic
plans and continue integrating
prevention and care services into a
Continuum of HIV/AIDS Services
that include both prevention and
care.
Meeting and minutes of
Commission and CPB
collaboration on a
consolidated strategic
plan.
Recommendation of a
single Continuum of
HIV/AIDS services.
Consolidated strategic
plan that includes
prevention and care.
3-6

10. Epidemiological, consumer, and patient data will be used to plan for the best combination
of services and used to allocate funds to services.
10.1. In 2005 the Commission will
continue to support enhanced
knowledge of disease trends and
improve regional surveillance and
cost efficiency through the
adoption of a name-based HIV
reporting system that maintains
privacy and identity safeguards
and protection of people
diagnosed as HIV positive. It will
replace the current statewide
code-based HIV reporting system
that was implemented three years
ago.
Commission sponsored
forums advocating names
base reporting.

Adoption of names
based HIV reporting.
10.2. In 2005, 2006, and 2007 the
Commission will continue to
support the HIV/AIDS Care
Assessment Project (H-CAP) to
collect consumer data on their
service needs, gaps, and barriers.
Contract to continue H-
CAP.
Delivery of H-CAP
reports as requested.
10.3. The Commission will continue
to pursue and actively participate
in research endeavors that assist
in planning activities and/or hones
in on best practices and/or new
innovative methodologies that
significantly improves the health
outcomes of PLWH/A.
Identification of research
efforts that help planning
activities.
Commission updates on
new innovative service
and protocols that
improve the health
outcomes of PLWH/A.
Commission adopts
new practices when
they are confirmed to
improve the health
outcomes of PLWH/A.
Commission directives
changing or adding to
standards.

work with African American,
Latino, API, and other
communities of color to
determine the most effective use
of Minority AIDS Initiative
(MAI) funds.
Special H-CAP reports
contracted for service
needs, barriers, and gaps
of communities of color.
Data distributed about
service needs, barriers,
and gaps identified for
communities of color.
Commission
recommends allocation
of MAI funds based on
research and other
community input.
3-7
create a subcommittee to work
with the American Indian Tribal
Council to encourage the
dissemination of culturally
appropriate messages to bring
HIV positive American Indians
into care.
Creation of Commission
subcommittee to work
with American Indian
Tribal Council.
Increased number of
American Indians
infected with
HIV/AIDS seeking
care.
11.3. In 2005 the Commission will
work with young gay men and
disseminate culturally appropriate
material regarding crystal meth
use, early detection, and early
treatment for those testing
positive.
dissemination of
information targeted to
young gay men.
Lower rates of drug use
and early treatment in
by young gay men in
H-CAP.
11.4. The Commission will sponsor a
task force to define and meet the
needs of the transgender
community.
task for on HIV/AIDS
care needs in transgender
community.
Targeted care services
targeted to transgender
community.

12.1. The Commission will develop a
set of seminars for new
Commissioners on the use of data
for planning and decision
making.
See 1.1 above See 1.1 above.
12.2. The Commission will debrief
with Commissioners on their use
and understanding of data.
Meeting of new
commissioners with
support staff on use of
data.
Improved
understanding and use
of data by
Commissioners.
3-8
INFRASTRUCTURE GOALS AND OBJECTIVES

13. Shared information on clients to reduce red tape, facilitate access to services, determine
eligibility, and the health status of patients.
13.1. Continuing in 2005, OAPP will
continue the development and
implementation of a real-time
web-enabled integrated client
database. This system will be
enhanced with the capacity to
have shared record management.
With proper confidentiality
procedures in place, intake will
be centralized and all providers
will have access to the same
client information. This
enhancement will expedite
clients access into care and will
reduce and service redundancy,
and check for eligibility for
CARE Act funded services as
well as Medi-Cal, Medicare, and
other reimbursement sources.
Benchmarks tests of web-
based client tracking
system.
Beta system released and
evaluated.
Release of web based
client tracking system.
Algorithm for eligibility
established.
Adoption of web-based
or compatible stand-
alone client tracking
system by all providers.
13.2. Continuing in 2005, OAPP will
implement HITS and
coordination prevention, HCT
and early treatment and care
services to encourage persons
who test positive to seek services.
Commission audit of
HITS and impact of it on
HCT early treatment and
care services.
Improved tracking of
persons testing positive
and not seeking care.
Decreased numbers of
PLWH/A who have
unmet need.
13.3. Develop case management
modules to measure acuity levels.
OAPP and Commission
adopt standard acuity
measures for intake
instrument.

Acuity documented and
tracked on all PLWH/A
in care.
13.4. Develop automated referrals and
automatic scheduling and e-
mails.
OAPP contracts module
in client tracking system
that allows referrals and
sends electronic
reminders to those with e-
mail.
Improved referral and
reminders for
appointments.
3-9

14. Identify alternate sources of funding to enhance local HIV service delivery systems.
14.1. Partners within the EMA will
continue to identify alternative
sources of funding for care
services.
Commission
dissemination of
information on alternative
funding sources to
providers and partners in
the administrative
mechanism.
Monitoring the non-Ryan
White CARE funds that
provide reimbursement
for services.
Added revenue per
capita of non Ryan
CARE Act funds in the
Continuum of Care.

15.1. Continuing in 2005, the
Commission will implement
strategies to improve measures
and enhance consumer
satisfaction through such
methods as Patient Bill of Rights
and Grievance Procedures.
Commission will sponsor
educational forums of
Patient Bill of Rights and
Grievance procedures.
Measure of PLWH/A
awareness of patient bill
of rights.

Knowledge of Patient
Bill of Rights and
grievance procedures
by PLWH/A.
4-1
4. ATTACHMENTS

Attachment 1 2004 Needs Assessment Survey
Attachment 2 Focus Group Outline for Selected Populations
Attachment 3 Focus Group Outline for Out-of-Care
Attachment 4 Secondary Information Sources
Attachment 5 SPA Descriptions
Attachment 6 Service Provider Network Plan
Attachment 7 Service Category Summary Sheet - Example
Attachment 8 Formula for Estimating PLWH/A
Attachment 9 Poverty Levels
Attachment 10 2004 Survey Cross Tabs
Attachment 11 2004 Survey Cross Tabs Selected Populations
Attachment 12 HIV/AIDS Interface Technology System (HITS) Project Description
Attachment 13 Community Advisory Boards and Consumer Involvement
Attachment 14 2002 Recommendations from the Assessment of the Administrative
Mechanism
Attachment 15 Core Service Program Indicators
Attachment 16 Goals and Objectives for Implementing Core HIV/AIDS Services

LA HIV/AIDS Comprehensive Care Plan: 2004

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PCH and County of Los Angeles December 2004

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