September 2001

HRSA Care ACTION

The AIDS epidemic first emerged in the United States among men who have sex with men (MSM) and, today, after significant reductions of AIDS morbidity and mortality, it is among that population that results from several studies signal a resurgence of risk-taking and HIV incidence. Most recently, results from the Young Men’s Survey revealed startling HIV incidence among some MSM populations, especially black MSM. Unfortunately, these results are not unique but instead echo results from several studies conducted over the past 5 years.

In addition to implications regarding increasing demand for scarce resources, these developments herald serious challenges for organizations working across the HIV prevention and care spectrum. They require us not only to refocus on the needs of MSM in general but also to successfully implement new CARE Act provisions regard-ing the participation of CARE Act grantees in the realms
of outreach, HIV counseling and testing, and early intervention services in general. (See the July 2001 issue of this publication.) Likewise, the promise of new provisions regarding linkages with points of entry into care must be realized, so that MSM have access both to the care that can help them lead healthy, productive lives, and to the “prevention-for-positives” interventions that can slow the spread of HIV infection. 

Of 2,942 men tested for HIV disease through Phase II of this CDC study, 373 were HIV positive, indicating an HIV prevalence of 13 percent overall; prevalence was 32 percent among blacks, 14 percent among Hispanics, and 7 percent among whites. The overall HIV incidence rate was 4.4 percent, but incidence among blacks, at 14.7 percent, was more than triple that rate. The rate for Hispanics was 3.5 1 percent, and 2.5 percent for whites.

Phase II of the Young Men’s Survey was conducted between 1998 and 2000 in six cities: Baltimore, Dallas, Los Angeles, Miami, New York, and Seattle. The research was not based on a representative sample of all MSM but included only young men who frequent certain public venues such as bars and parks. Nonetheless, the results reveal extremely high HIV incidence among some MSM subpopulations. 

The Stop AIDS Project Survey

In standardized annual surveys conducted from 1994 through 1997, the Stop AIDS Project, a San Francisco community-based organization, collected information on 2 demographics and sexual behavior from 21,857 MSM.

Results showed that the proportion of MSM who reported having anal sex increased from 57.6 percent in 1994 to 61.2 percent in 1997. Of those who had anal sex, the proportion reporting that they "always" used condoms declined from 69.6 percent in 1994 to 60.8 percent in 1997. The most pronounced decline in consistent condom use during the survey period appeared among MSM ages 26 to 29: from 68.2 percent in 1994 to 58.0 percent in 1997. Additionally, the survey found that the proportion of MSM reporting having had multiple sex partners and unprotected anal intercourse during the previous 6 months increased from 3 23.6 percent in 1994 to 33.3 percent in 1997.

During this same period, the San Francisco Department of Health reported an increase in the annual incidence of male rectal gonorrhea (from 21 cases per 100,000 adult men in 1994 to 38 cases per 100,000 adult men in 1997), following a decline in annual incidence from 1990 through 1993 (from 42 cases per 100,000 adult men in 1990 to 20 cases per 4 100,000 adult men in 1993).

Researchers analyzed data from the Gonococcal Isolate Surveillance Project (GISP) from 1993 through 1996 to assess trends in gonococcal infection among MSM in eight large U.S. cities. MSM constituted 5 percent of all cases in the GISP sample in 1993, a proportion similar to that in 5 preceding years, but increased to 8.7 percent by 1996.

Clinics in Seattle, Portland, and San Francisco saw increases in both the absolute number and proportion of gonorrhea cases among MSM. From 1994 to 1996 in Seattle, for example, the number of cases among MSM increased by 125 percent, but the number of clinic visits by MSM increased by only 17 percent. Clinics in Honolulu and San Diego reported substantial increases in the number of gonorrhea cases among MSM. At the Denver clinic from 1995 to 1996, the absolute number of MSM gonorrhea cases decreased, but the proportion of cases among MSM increased. In addition, when compared with the other clinics during the same period, the Denver clinic saw an increase in the number of black MSM examined. Researchers report that  the trends cannot be explained by such factors as improved case ascertainment or increased screening efforts in the MSM population. The survey also noted increases in rectal gonorrhea cases at several of the clinics, an indicator of 6 unprotected anal intercourse.

In the first one-half of 2000, five health jurisdictions in southern California experienced an outbreak of syphilis among MSM, many of whom were HIV positive. The proportion of primary and secondary syphilis cases among MSM increased from 26 percent to 51 percent from July 1999 to July 2000. Behavioral data collected from the cases suggest that an increasing number of MSM are participating in high-risk sexual behavior that puts them at risk for 7 syphilis and HIV infection.

Because of the sharp increase in cases among MSM reported in the first one-half of 2000, records for patients in whom syphilis was reported between January 1999 and July 2000 were reexamined. Of the 130 patients re-interviewed, 66 were MSM. Among MSM cases, 50 percent reported that they had had anonymous sex, 26 percent had met sex partners in bathhouses, and 20 percent reported that they had used a condom during their most recent 8 sexual contact.

A number of studies have found a connection between the 9 use of alcohol or drugs and sexual risk taking among MSM.  In a survey of 508 young gay men (77.6 percent were white; 76.4 percent were in college) recruited between 1994 and 1995 from Boston bars, college campuses, and the Fenway Community Health Center, researchers found that the role of alcohol in unsafe sex between young gay men is complex, with situational factors playing a key part. Twenty-six percent of the respondents reported unprotected anal intercourse in the preceding 6 months. These individuals were more likely to have a drinking problem (odds ratio=1.95) and drank more (20.4 m/day versus 13.9 m/day) phan individuals who did not engage in unprotected anal 10 intercourse.

In the study, men were significantly more likely to have unprotected anal intercourse with their nonsteady sexual partners after drinking than when they were sober (odds ratio=4.33), but they were significantly less likely to have unprotected anal intercourse with their steady partners 11 (odds ratio=0.27).

In a study to assess the characteristics associated with age and recent unprotected anal sex with casual partners among 455 MSM in Montreal, researchers found that age did not predict risky sexual behavior. Roughly the same proportion of younger MSM (under age 30) as older MSM (age 30 or older) reported recent unprotected anal sex with casual partners (13 percent and 12 percent, respectively). The predictors for recent unprotected anal sex with a casual partner included alcohol and drug use before anal sex, not living with a male sexual partner, unprotected anal sex with a regular partner, and having had 12 sex with more than five partners.

AIDS first emerged in the United States most predominately among white MSM, but much has changed since then. In 1989, racial and ethnic minorities made up 31 percent of all new AIDS cases for which the HIV exposure category was MSM; by 1998 that proportion had grown 13 to 52 percent. The epidemic has had a particularly devastating effect on African Americans: Although African Americans make up about 12 percent of the U.S. population, they accounted for 47 percent of the newly reported AIDS 14, 15 cases in 2000. Among African American men for whom AIDS cases have been reported, MSM is the leading HIV 16 exposure category, at 42 percent in 1999.

The Hispanic community has been disproportionately affected by the AIDS epidemic as well. Although Hispanics constitute approximately 13 percent of the U.S. population (including Puerto Rico), they represented 19.5 percent of the total number of new adult and adolescent AIDS cases 17 and 16.8 percent of the pediatric AIDS cases in 2000. The AIDS rate for Hispanic adults and adolescents was 30.4 per 18 100,000 population, nearly 3 times the rate in whites.

African Americans and Hispanics suffer disproportionate rates of problems known to be associated with risk for HIV infection, including lower rates of employment and 19,20 insurance coverage. Even among the insured, however, race still predicts health care utilization. Among men with private insurance coverage, a Kaiser study found that 19 percent of Hispanics and 16 percent of African Americans in fair to poor health reported no doctor visits during the previous year, compared with 12 percent for non-Hispanic 21 whites.

A study conducted from 1991 to 1996 among a cohort of well-educated, well-insured, middle- to high-income HIV positive men in Baltimore examined the relationship between race and health service use. Researchers found that, controlling for all socioeconomic and health factors, HIV-infected white men were three times more likely than HIV-infected African American men to have visited a doctor in the 6 months prior to being questioned. In addition, only 45 percent of the HIV-infected African American men had seen a dentist in the previous 6 months, compared with 62 22 percent of the HIV-infected white men.

AIDS service organizations, community-based organizations, and others providing services supported by CARE Act funds continually adapt their programs to both anticipate and respond to changes in the epidemic. An examination of how providers in the field are responding to the crisis among MSM illustrates a determination to meet existing needs and to serve the most hard-to-reach populations. Major changes in the CARE Act legislation reflect a broad Federal mandate to reach people who are HIV positive and bring them into care. Changes brought about by reauthorization in 2000, particularly those funding early intervention services through Titles I and II, have expanded the arsenal with which providers may fight the AIDS epidemic.

Consider the activities of New York City’s Callen-Lorde Community Health Center, which provides both prevention and care services through funds from several sources. The health center is seeking to link HIV-infected MSM with care by augmenting pretest HIV counseling. By expanding the traditional approach to counseling into several pretest sessions, risk reduction can be explored in greater detail, and the health center is better able to predict the range of services needed by each person who comes into care. Callen-Lorde is also providing case management at the time HIV-positive test results are given  to clients in order to provide emotional support, begin building a relationship with the client, and eliminate the barrier embodied in asking the client to come back at a later date for his first case management encounter. 

Other providers have taken similar steps to link HIV-positive MSM with care. In Seattle, for example, where a high proportion of HIV infections has traditionally been among MSM, a health educator is now providing prevention-for-positives’ interventions among HIV-positive clients at the Harborview Medical Center—an activity supported by CARE Act Title I funds. Additionally, counseling and testing protocols have been expanded so that post-test counseling includes a session with a peer educator; the objectives are to link individuals with care immediately upon learning their serostatus and to avoid the time lag that often occurs between testing positive for HIV infection and entering care. Through an outreach worker funded under Title III, Harborview goes into the community to conduct outreach interventions and offers case management capable of addressing complex cases, such as those in which violence, incarceration, substance abuse, or mental illness is a factor.

Many MSM lack the support network necessary for promoting behavior change and ensuring attention to prevention and care challenges. To address this challenge, many CARE Act grantees offer counseling and related services to help men cope with HIV infection and adopt prevention behaviors. "Many needs among MSM can be tied to the absence of a supportive environment," says Steve Morin of the University of California at San Francisco’s Center for AIDS Prevention Studies. "Support groups don’t naturally occur in families for many MSM," he adds. Morin stresses the role of social supports for MSM in both adopting preventive behaviors and coping with HIV infection. He notes that results from focus groups among young men of color suggest high levels of misunderstanding about antiretroviral therapy and what it does and does not accomplish. "There is more optimism about curing HIV infection, particularly among African American MSM, than is found among clinicians," Morin observes.

Why do people not adopt preventive behaviors? The answer is complex. With what we know about cancer, why do so many of us continue to smoke? With what is known about risk for heart disease and stroke, why are so many of us overweight? With what is known about road safety, why do so many of us bullet down the highway without a thought to wearing a seat belt?

Alarming evidence revealing sexual risk among some MSM produces a similar question: With what we know about how HIV is transmitted, why do people continue to become infected?

Certainly, lack of access to information remains a problem in the United States, but many people are practicing behaviors that increase their risk for HIV infection despite what they know, not because of what they do not know.  Health educators have known for some time that knowledge alone does not often lead to behavior change.

For many, but certainly not all people, the influence of alcohol and other drugs is a deciding factor. Others misunderstand the power of modern therapy: According to the former executive director of one of the Nation's largest community-based organizations serving gay men: 

"The cocktail is seen as a cure. People believe they are invulnerable." Karen Yen, field coordinator for the Baltimore portion of the Young Men’s Survey concurs, adding that "for young men, HIV has the stigma of being an older gay man’s disease. The story goes something like, ‘If I sleep with someone young who looks healthy, I can’t get infected.’" Psychological issues are also a major force: Many MSM live with debilitating lack of support, shame, and low self-esteem. These problems interplay with stigma and isolation for sexual minorities and cannot help but influence decisions about behavior. Whatever the reasons—and there are many—the implications for the CARE Act community are of significant need for services among MSM and construction of an environment in which behavioral change is possible.

References

1. CDC, Morbidity and Mortality Weekly Report, 50(21):440-444, 2001.

2. CDC, Morbidity and Mortality Weekly Report, 48(03):45-48, 1999.

3. CDC, Morbidity and Mortality Weekly Report, 48(03):45-48, 1999.

4. CDC, Morbidity and Mortality Weekly Report, 48(03):45-48, 1999.

5. CDC, Morbidity and Mortality Weekly Report, 46(38):889-892, 1997.

6. CDC, Morbidity and Mortality Weekly Report, 46(38):889-892, 1997.

7. CDC, Morbidity and Mortality Weekly Report, 50(07):117-120, 2001.

8. CDC, Morbidity and Mortality Weekly Report, 50(07):117-120, 2001.

9. S. A. Strathdee, et al., Determinants of sexual risk-taking among young HIV-negative gay and bisexual men. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology 19:61-66, 1998.

10. G. R. Sealge, III, et al., The social context of drinking, drug use, and unsafe sex in the Boston young men study. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology 17:368-375, 1998.

11. Sealge et al., 1998.

12. A. Dufour, et al., Correlates of risky behavior among young and older men having sexual relations with men in Montreal, Quebec, Canada. Journal of Acquired Immune Deficiency Syndromes 23:272-278, 2000.

13. CDC, Morbidity and Mortality Weekly Report, 49(01):4-11, 2000.

14. E. M. Grieco and R.C. Cassidy, U.S. Census Overview of Race and Hispanic Origin 2000: Census 2000 Brief U.S. Department of Commerce, Economics and Statistics Administration, U.S. Census Bureau, March 2001. p. 3.

15. CDC, HIV/AIDS Surveillance Report, 12(2):18, 20, 2001.

Title III Early Intervention Services 1999 Program Data

Early Intervention Services (EIS) grants funded through Title III of the Ryan White CARE Act support early intervention services and outpatient primary care for individuals living with HIV disease. Grantees are public or nonprofit private organizations that provide comprehensive primary care services to people at risk for HIV infection.

The goal of the Title III EIS program is to identify people with HIV and link them with health care and other essential services as early after infection as possible. Title III EIS funds are used to provide services in five categories:

Counseling, testing , and referral
Primary health care
Referral for health services
Outreach
Case management.

At least 50 percent of EIS grant funding must be used to provide primary care.

According to program data complied by HRSA, 108,945 individuals living with HIV disease received primary health care services through the Title III EIS program in 1999. Of those individuals, 26,991 were new clients. During the same year, 355,403 people received counseling, testing, and referral services, and 105,662 received case management services. A total of 741,802 outreach encounters were provided. (Some individuals may have received more than one outreach intervention.) 

From 1998 to 1999, the number of clients receiving primary health care increased 3.36 percent. The increase was 7.6 percent for referrals and 11.7 percent for case management. The number of clients who received counseling and testing decreased by approximately 5 percent, and the number of outreach interventions increased by about the same proportion (see chart).

Grantees in 44 States and the District of Columbia and Puerto Rico received Title III EIS funding in 1999. Of the 198 grantees, 173 are represented in the program data. (New grantees are not required to submit data, although 4 of the 24 did so. Five grantees submitted incomplete data and were therefore not included in the 1999 data.) Thirty-four percent of all grantees were federally funded Community and Migrant Health Centers, and 27 percent were university and hospital medical centers. The remainder were nonfederal health centers and other clinics (23 percent) and city and county health departments (16 percent).

Title III early intervention services reach people from all population groups. Grantees, however, may target specific populations within their service areas whom they have identified as most in need of HIV-related care. In 1999, those populations ranged from women and children to runaway youth and migrant workers (see table).

Gender and Race/Ethnicity. Title III EIS grantees served 77,734 male clients in 1999. Of those, 29,334 were African American; 28,334 were white; 18,123 were Hispanic; and 983 were from other racial backgrounds. Race/ethnicity was unknown or unreported for 960 males. Title III funds also provided services to 31,075 females in 1999, among whom 17,733 were African American; 5,700 were white; 6,976 were Hispanic; and 307 were from other racial backgrounds. Race/ethnicity was unknown or unreported for 359 females. 

Age. Forty-one percent of Title III EIS clients were between ages 30 and 39, and 31 percent were between ages 40 and 49. Age was reported for 107,635 of the 108,945 Title III clients receiving primary health care services in 1999; data were unknown, unreported, or missing for 1,310 clients. The number of patients served in the 30 to 39, 40 to 49, and 50+ age categories have increased significantly since 1996.  Patients in the 50+ age group accounted for the largest increase, growing from 7,039 in 1996 to 12,022 in 1999; an increase of 71 percent. Over the same 4-year period, patients in the 40 to 49 age group increased 58 percent, and those in the 30 to 39 age group increased 19 percent.

Stage of Disease. Title III EIS providers report stage of disease data for new primary care clients, of whom approximately 90 percent, or 24,267, are represented in the 1999 data report. Of those individuals, only 30 percent + (7,192) had CD4 lymphocyte counts (T-cell counts) of at least 500 upon entering care at a Title III site.

Of the remaining 70 percent, approximately one-half entered care with T-cell counts of less than 200, and one-half had counts between 200 and 499. Of those individuals, almost one-third had an AIDS-defining condition, and an  additional 26.4 percent had symptomatic conditions. Just 41 percent were living with asymptomatic HIV infection.

Title III program data provide information on the source of payment for new primary health care patients only. Of the 27,354 patients, 47 percent had no insurance coverage. Medicaid provided for 29 percent of patients; 9 percent of patients were covered by private companies, 8 percent by other entities, and 7 percent by Medicare. The proportion of new clients in each category of payment source remained relatively consistent from 1995 through 1999. After a slight decline in 1997 and 1998, the number of patients who reported having no insurance increased in 1999, although the total without insurance remains lower than it was in 1995. Since 1995, the number of patients covered by Medicare or private insurance has increased slightly, whereas the number reporting Medicaid coverage has declined.

Grantees spent $75,353,313 in Title III funds to provide early intervention services to eligible clients in 1999. Seventy-nine percent of all Title III funds were spent on primary health care services, which include medical, dental, mental health, nutrition, and substance use evaluation or treatment; pharmacy services; and radiology, laboratory, and other tests used for diagnosis and treatment planning. Title III expenditures for primary health care increased 98 percent between 1995 and 1999, in part because annual Title III appropriations increased from $52.3 million to $94.3 million during that time. Title III expenditures for counseling and testing, referrals, outreach, and case management services remained constant during the 5-year period.

The total appropriation for the Ryan White CARE Act in FY 2001 was $1.8 billion. Of this amount, $185.9 million was appropriated to Title III. 

In addition to EIS grants, Title III funds planning grants that help organizations prepare for delivering HIV-related services in the future. Currently, Title III funds support 254 early intervention programs and 93 planning grant programs. An additional Title III program was added when the Ryan White CARE Act Amendments were signed into law in November 2000. Planning grants are now of two types. The first type prepares organizations to provide EIS. This grant may not exceed $50,000 and is for a 1-year period. The second type of planning grant covers 3 years, for a total of up to $150,000, and is used to promote capacity building for HIV health services in underserved communities.

For additional information about the Title III program, see the Title III Fact Sheet and Grantee List at http://hab.hrsa.gov/publications.html or the Title III 1999 Data Report Summary at http://hab.hrsa.gov/data.html. 

Implementation of New Provisions in the Reauthorized CARE Act

The reauthorized Ryan White CARE Act includes new provisions that were adopted to improve access to care and quality of care for people living with HIV disease. Some provisions are broad in scope, such as those regarding the feasibility of using HIV prevalence rather than AIDS prevalence in allocating formula grants to Eligible Metropolitan Areas (Title I) and States and Territories (Title II). Others relate more specifically to a particular program; for example, two types of planning grants are now available through Title III.

HRSA, through the HIV/AIDS Bureau (HAB), is responsible for administering the CARE Act and is charged with implementing changes in the law. The HAB Office of Science and Epidemiology (OSE) has incorporated the hold harmless, minimum allotment, and distribution of funds to territories provisions regarding Titles I and II. The office has also calculated formula grants for emerging communities in accordance with provision II.207.(1)-(2). In addition, OSE is facilitating two studies by the Institute of Medicine that are mandated in the legislation. The first study relates to using HIV prevalence rather than AIDS prevalence as a basis for calculating formula grants, and the other concerns the financing of HIV/AIDS care. Both are to be completed by  2003. OSE is also charged with supporting the development of estimates of unmet need and of severe need. Results will be reflected in allocation formulas over the next 5 years.

Through the HAB Division of Service Systems (DSS), the agency has issued letters and guidances pertaining to several changes and new provisions, including composition and responsibilities of planning councils; comprehensive planning; public meetings; measuring and responding to unmet need; quality management; and using Title I and II funds for early inter vention , referral , and quality improvement activities. DSS has also developed technical assistance materials and is holding regional technical assistance meetings in an effort to enhance the grantees’ awareness of changes in the law and ensure compliance with new provisions of the law.

Other changes in the CARE Act are already, or will soon be, reflected in program guidances. HAB’s Division of Training and Technical Assistance is available to assist grantees as they work to comply with new provisions in the law. For access to technical assistance, CARE Act grantees should contact their project officer.

For more information, call (301) 443-7036

http://hab.hrsa.gov

HEALTH RESOURCES AND SERVICES ADMINISTRATION -  HIV/AIDS BUREAU

IN THIS ISSUE
Title III Early Intervention Services 1999 Program Data
Insert: Calendar of Events

HRSA Care ACTION
is published by the HIV/AIDS Bureau,
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HRSA Care ACTION
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