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Barriers to Human Immunodeficiency Virus Prevention and Care
Barriers to HIV/AIDS Prevention and Care for Gay and MSM African American Males 18-24
Rene’ Walling, Elena Costa, Jennifer Manibot,
Ronn Gonzales, Esther Campos and Esmeralda Mendoza
California State University Sacramento 144-02
Barriers to Human Immunodeficiency Virus Prevention and Care 2
Acknowledgement
To complete this grant assignment, we gratefully accepted the help and guidance of some
revered persons, who deserve our sincere appreciation. We acknowledge our gratitude of Dr.
Diaz, professor with the California State University, Sacramento, for providing us with guidance
through the development of this grant, clarification of numerous questions, and for assistance
navigating comprehensive written instructions. Additionally, we thank all who supported us
explicitly in our work as well as those who did so indirectly. A great deal of individuals
supported us, from our direct teammates to our fellow classmates, whom offered suggestions that
led to direct improvements to this project.
Barriers to Human Immunodeficiency Virus Prevention and Care 3
Abstract
Within Sacramento County, disproportionately high numbers of African American males are
contracting HIV infection each year. Historically African Americans struggled with oppression,
unequitable treatment from society due to racism, and a tendency to utilize healthcare services at
far lower rates than other ethnic groups. Research explains that the gay and MSM community,
regardless of ethnic group, tend to utilize health services far less overall, due to mistrust of
medical service providers. Now that the Affordable Care act has built bridges to treatment and
care, ensuring linkages are available to all, the time to act is now to create opportunities for
access to care for this high risk group. The cost of even one case of HIV over the course of a
lifetime in both emotional, physical and financial burdens is one that society has a responsibility
to address. In the Know will create access to care for gay African American males and MSM in
Sacramento County by way of the PrEP for Love Program. PrEP for Love focuses on reducing
HIV infection by use of sexual health information, easy access to the pre-exposure prophylactic
medication Truvada, linkage to culturally responsive health providers for long-term care, and
assistance with obtaining health insurance coverage as needed. To ensure that PrEP for Love
utilizes a complete and thorough approach to reducing area infection rates, In the Know sought
out input from a similar project in San Francisco, California. Their approach with both sexual
health education and access to PrEP was so successful, they had zero cases of HIV infection
during the life cycle of the project. In the Know intends to replicate their work and utilize
partnerships with area service providers to reach 75 participants over the course of twenty-six
months. This innovative approach to provide access to care will reduce the overall burden of
cost of new HIV patients, empower the MSM community, and provide safer sex education.
Barriers to Human Immunodeficiency Virus Prevention and Care 4
TABLE OF CONTENTS
ACKNOWLEDGEMENTS…………………………………………………………………...…….....2
ABSTRACT…………………………………………………………………………………..…......3
TABLE OF CONTENTS…..……………………………………………………...……...………......4
STATEMENT OF PROBLEM…..………………………………………………………...……….….6
TARGET POPULATION…………………………………………………………………………….7
DATA/INFORMATION
NATIONAL..……………………………………………………………………………......7
STATE…..…………………………………………………….…………………………....8
LOCAL…..………………………………………………………………………………....9
UNDERSTANDING OF PROBLEM
SOCIAL....……………………………………………………………………..…..……...11
POLITICAL…..………..…………………………………………………………..………12
EDUCATIONAL……………………………………………………………………………14
ENVIRONMENTAL…..…………………………………………………………………….15
CULTURAL CONSIDERATIONS…..………………...……………………………………...16
POLICY
EXISTING POLICIES, SERVICES AND PROGRAMS…..……………………..………………18
CURRENT IMPORTANCE TO ADDRESS ISSUE……………………………………………..19
PROPOSAL
DETAILS OF PROPOSAL………………………………………………………………..…20
PARTNER ORGANIZATIONS………………………………………………………………22
COMMUNITY INVOLVEMENT…………………………………………………………….23
PROGRAM PLANNING MODEL……………………………………………………………23
Barriers to Human Immunodeficiency Virus Prevention and Care 5
PROGRAM GOALS & OBJECTIVES
PROGRAM GOALS…………………………………………………………………………24
OVER ALL PROGRAM OBJECTIVES………………………………………………………..24
LEARNING OBJECTIVES…………………………………………………………………...25
BEHAVIORAL OBJECTIVES………………………………………………………………...25
ENVIRONMENTAL OBJECTIVES…………………………………………………………...26
PROCESS OBJECTIVES……………………………………………………………………..26
EVALUATION MATRIX…………………………………………………………………………...26
TIMELINE………………………………………………………………………………………...28
EVALUATION…………………………………………………………………………………….29
ORGANIZATIONAL CAPACITY…………………………………………………………………...31
RISK ANALYSIS…………………………………………………………………………………..33
REFERENCES………….…..………………………………..………...…………………………..36
APPENDICES
MARKETING……………………………………………………………………………….42
LINE ITEM BUDGET………………………………………………………………..………44
BUDGET NARRATIVE………………………………………………………………………45
Barriers to Human Immunodeficiency Virus Prevention and Care 6
Statement of Problem
HIV infection rates among Sacramento County men of color, namely African American
men who identify as gay or as men who sleep with men, (MSM) are rising. Sacramento County
ranks 8out of the 58 counties within California for cases of HIV, this is of serious concern and
must be addressed to impede the infection rate of HIV in Sacramento County (Office of AIDS,
2014). The Centers of Disease Control (2014, p.2) explain, “gay, bisexual, and other men who
have sex with men, particularly young black/African American MSM, are most seriously
affected by HIV.” Youth are the individuals who are at highest risk for new HIV infection. The
CDC also highlights, “in 2010, the estimated number of new HIV infections was highest among
individuals aged 25-34, followed by individuals aged 13-24” (2014, p.2).
Many factors are at play concerning this trend of rising HIV infections, however, it is
clear that access to care is at the forefront of the issue. “Nearly a quarter of African-American
and Latino families live in poverty, which can limit access to HIV testing and medical care.
Homophobia and HIV stigma, far too common in all communities, can discourage individuals
from seeking HIV testing, prevention and treatment services. Other barriers to HIV testing and
care include discrimination, unstable housing and low rates of health insurance coverage” (CDC,
2014, p.9). Health insurance coverage, along with engagement in regular visits to a medical
provider, are vital components to link individuals to the preventative health services necessary to
care for chronic issues, as well as health education in general. Research by McKiernan, D., Bois,
S., Alvy, L., & Jones, K., (2013, p. 40) uncovered that those who exclusively identified as MSM
and were also African American, “had reduced access as compared with Caucasians, that income
was positively related to access, which are consistent with the trends reported among the general
population.”
Barriers to Human Immunodeficiency Virus Prevention and Care 7
Target Population
The target population is African American males who self-identify as gay or as MSM,
between the ages of 18-24. The target location is Sacramento County, in the city of Sacramento,
CA, specifically the ZIP codes 95811 & 95814 in the midtown area.
Data/Information
National: The Centers for Disease Control and Prevention indicate that, “more than 1.2
million people in the United States are living with HIV infection and almost 1 in 7 (14%) are
unaware of their infection” (CDC, 2014, November 25, para. 1). Men who identify as gay,
bisexual, and MSM who are young black and African American, are most seriously affected by
HIV. From 2008 to 2010, “the greatest number of HIV infections was among MSM aged 13 to
24, and teen African Americans continue to bear a disproportionate number of new HIV
infections” (CDC, 2014, November 25, para. 3). Young gay African American males between
the ages 13-24, who are involved in gay sex, have the highest estimated total of new HIV
infections (4,800). “This group also accounts for 45% of the new HIV infections among gay
African American men and MSM, as well as 55% of the new HIV infections among young MSM
overall” (CDC, 2014, November 25, para. 9). The much smaller rate of 21% of new HIV
infections is among Hispanics and Latinos in 2010; this comparison highlights the urgency with
which the high rates among African Americans need to be addressed (CDC, 2014, November 25,
para. 19).
According to the Centers for Disease Control and Prevention, “since the epidemic began,
an estimated 265,812 African Americans with AIDS diagnosis have died, including an estimated
6,630 in 2011” (CDC, 2014, November 25, para. 10). The organization also states that “unless
the course of HIV infection in the United States changes at some point in their lifetime, an
Barriers to Human Immunodeficiency Virus Prevention and Care 8
estimated 1 in 16 African American men and 1 in 32 African American women will be
diagnosed with HIV infection” (CDC, 2014, November 25, para.14). Furthermore, statistical
data from 2010 indicated that “75% of HIV-infected African Americans aged 13 or older are
linked to care, 48% are retained in care, 46% are prescribed antiretroviral therapy, and only 35%
are virally suppressed” (CDC, 2014, December 8, para. 10). The CDC (2005, June 22) also
mentions a study on prevalence within groups of African American males, which found upon
close of inspection of the rates in the United States among five major cities, nearly 50% of all
gay African American men and bisexual men were HIV-positive, additionally the number of
people living with HIV has increased, while the annual number of new HIV infections has
remained relatively stable. The facts that the CDC provides are validations that the target
population needs some kind of support in order to suppress the issue. Existing governmental
policies should be reviewed in order to help the people involved in this matter.
State: According to the California Department of Public Health (2014), cumulative HIV
and AIDS cases in California, total 18,434 for African Americans (4,589 HIV cases and 13,845
AIDS cases) that were exposed through gay sexual activity. In addition to this, the California
Department of Public Health (2014) also reports that approximately 70% of all newly HIV
infected African Americans were exposed through MSM activity and injection drug use. In 2011
the total estimate of adults and adolescents diagnosed with HIV due to MSM activity in
California in 2011 was 78.3%, with 20% of these cases occurring in African American males
(California Department of Public Health, 2014). The San Francisco Aids Foundation calculates
that about 134,158 people are living with HIV in California (Statistics-San Francisco AIDS
Foundation, n.d.). The AIDS incidence rate per 100,000 population among African Americans
in the state of California is three times higher than the rate for Caucasians and Latinos in 2006,
Barriers to Human Immunodeficiency Virus Prevention and Care 9
32.35/100,000 versus 9.6/100,000 and 9.67/100,000, respectively (California Department of
Public Health, 2014, June 30).
Lastly, HIV is also being largely transmitted within hostile environments, such as county
jails and prisons. The Bureau of Justice reports in their 2001 statistics bulletin, that in 1999,
California ranked 4th for the highest number of AIDS cases in United States prisons in (Bureau
of Justice Statistics Bulletin, 1999). The Sacramento Court Grand Jury report states that, “HIV
positive inmates are not required to be segregated from other prisoners during their time in
prison” (Sacramento County Main Jail, 1999, para 5). It is a known fact that blood borne
diseases can be easily spread in aggressive environments like prisons. Policies and procedures
are needed to protect inmates and decrease the spread of AIDS within local and federal prisons.
Local: The prevalence of AIDS and HIV in Sacramento County should be of enormous
concern. According to the California Department of Public Health, (2014, June 6) Sacramento
County ranks in the top 10 cities for HIV and AIDS. This is especially accurate for the
combined ZIP codes of 95811 and 95814, which have had the highest amassed cases of AIDS
among the County of Sacramento, from 1982 to 2007 (County of Sacramento Quarterly AIDS
Report, 2008). According to National HIV Testing Day, (2009, June 27) from the County of
Sacramento’s Department of Health and Human Services, African Americans represented 22%
of reported cases, all though they only made up 11% of Sacramento County’s population.
The California Department of Public Health’s semiannual report (2014, June 30)
indicates that Sacramento has a total of 1627 HIV cases, 1545 living cases and 82 (5%)
deceased. The Sacramento Pride organization (n.d.) reports that the City of Sacramento is
estimated to have a gay population of 9.8%, the sixth highest in the nation and more than the
national average of 4.1%. The Pride Institute is the organization responsible for managing the
Barriers to Human Immunodeficiency Virus Prevention and Care 10
Sacramento Pride Parade that is held in ZIP codes 95814 and 95811. The Sacramento Gay Pride
Parade is known as one of the largest sources of funding for programs and services at the LGBT
community center in Sacramento. The LGBT center provides HIV and AIDS testing, transgender
support and other activities that serve the community (Sacramento Pride, n.d.).
The Lavender Heights District is also located within the Sacramento ZIP 95811. The
Lavender heights District is a place known for its high numbers of gay-owned businesses.
Ron Jones of CBS Sacramento, (2014, December 15) declares that local community activists are
making a push in midtown to honor the LGBT community and affiliated businesses to promote
the gay community. Local activists are also pushing that the nickname “Lavender Heights” be
made the official title of the area. Advocates would also like to include custom made street signs
and rainbow-colored cross walks and flags throughout the area (Jones, 2014). These realities
validate the activity of the LGBT community in our focus area and the need for assistance in
improving all aspects of a gay lifestyle, including equal access to healthcare.
The Sacramento Department of Health and Human Services (2015a) reports that ZIP
code 95814 has only two HIV testing sites. Sharing syringes for injection drug use is one major
pathway for the spread of blood borne diseases. As of April 2014, there are two pharmacies that
participate in the “non-prescription sale of syringes” in the ZIP codes 95814 and 95811. People
who are actively using syringes for illegal drug use are more likely to share if they do not have
access to new ones. When this happens, HIV and AIDS, as well as other diseases can be easily
passed from person to person, in addition to sexual partners (Department of Health and Human
Services, 2015b). This issue is clearly related to healthcare access and currently impacts this
populations chance to avoid HIV transmission via syringe, additionally, not having proper access
Barriers to Human Immunodeficiency Virus Prevention and Care 11
to health care increases the risk of death among African Americans, once diagnosed with AIDS
(HIV & AIDS Among African Americans, n.d.).
Understanding of Problem
Social: The plight of all African Americans dates back to the infamous early days of
slavery, however the strong sense of inequality and racism displayed by affluent Caucasian
slaveholders and communities alike, has burned its negative influence into the minds of
preceding and present generations. The stark reality is, simply being African American is a
strong indication that HIV infection will occur. Inequalities within the African American
community demonstrate why social influences have such a negative impact upon disease
infection and poor treatment outcomes. The social implications are apparent in the high rates of
unemployment, incarceration, drug use and lack of education among African Americans, to
name just a few.
It is a common misconception that gay men are somehow more affluent and well off than
their heterosexual counterparts. According to the Bureau of Labor Statistics, the overall
unemployment rate for the Unites States in 2013 was 7.4%, alarmingly, for this same year the
rate is almost double for African Americans at 13.1% (Bureau of Labor Statistics, 2014). Not
surprisingly, the average income of African Americans is also comparatively low, even for those
able to acquire employment. For 2013, the U.S. Census Bureau (2014) states that the median
income for the United States was $51,939; African American households earned nearly 30%
less, with a median income of $34,598 (DeNavas-Walt, & Proctor, 2014). Additionally African
American gay men and MSM may struggle with feelings of discrimination from the medical
community. The combination of low income and reluctance to seek medical care leaves many
vulnerable to infection and lack of care for ongoing conditions, such as aids (Moyer, 2011).
Barriers to Human Immunodeficiency Virus Prevention and Care 12
The isolation is further exemplified by “the widespread perception of high HIV
prevalence among the African American community, which in turn increases the stigma and
discrimination that members of the community who are living with HIV experience” (HIV &
AIDS Among African Americans | AVERT. n.d., para. 47). These disparities within our
communities, increase the likelihood of African American MSM choosing sexual partners within
their race, thus concentrating the already high prevalence of HIV further within African
American society (HIV & AIDS Among African Americans | AVERT. n.d.).
The stigma associated with homosexuality is also a contributing factor to the high rate of
HIV/AIDS among African American MSM. Many prioritize keeping their status as a gay man
secretive, forgoing the medical treatment needed for associated STI’s and HIV/AIDS treatment
and screening. Those who live in poverty are also less likely to have access to medical treatment
and may go longer periods of time either unaware they are infected with HIV or an STI, or
without treatment for it (Understanding Disparities in the HIV Epidemic, n.d.). Societal
pressures influence and promote the emotional stress that result in risk taking health behaviors
and the HIV epidemic among young African American MSM (between the ages of 13 and 24) in
the USA (HIV & AIDS Among African Americans | AVERT. n.d.).
Political: According to HIV & AIDS Among African Americans, (n.d.) not having
proper access to health care increases the risk of dying among African Americans, once
diagnosed with AIDS. Compared to other racial and ethnic groups, the risk of contracting HIV is
also higher among African Americans (The Affordable Care Act and HIV/AIDS, 2014). One of
the very first programs that has contributed to improving healthcare access is the Ryan White
Program, enacted in 1990. Health care providers agree that this program has provided high-
quality care for those affected with the disease (Sood, Juday, Vanderpuve-Orgle, Rosenblatt,
Barriers to Human Immunodeficiency Virus Prevention and Care 13
Romley, et al., 2014). Medical care for HIV is financially demanding, and serves as a barrier to
care for many ethnic minorities, such as African Americans. In the article, “HIV Care Providers
Emphasize the Importance of The Ryan White Program for Access to and Quality of Care,” HIV
patients are described as, “poor with unstable living conditions, are uninsured or-underinsured”
(Sood, Juday, Vanderpuve-Orgle, Rosenblatt, Romley, et al., 2014, para. 2).
Before the Affordable Care Act (Obama Care) was implemented on March 23, 2010,
access to health care remained an obstacle for those infected with HIV and AIDS, despite
implementation of previous programs. Today Obama Care ensures coverage for preventive
services like HIV testing, lowered medical costs, expanded Medicaid coverage, provides more
affordable private health coverage, and ensured coverage for people with pre-existing conditions
(The Affordable Care Act and HIV/AIDS, 2014). Before this triumph in the healthcare system,
anyone with a pre-existing health condition like HIV and AIDS could be denied coverage or
care. HIV and AIDS patients no longer have to fear the possibility of being denied care. In
collaboration with the Affordable Care Act, the National HIV/AIDS Strategy released on July
13, 2010 by President Obama, has made efforts to research, prevent, and treat HIV (The
Affordable Care Act and HIV/AIDS, 2014). Goals for the strategy include but are not limited to,
reducing HIV infections, increasing access to care, improving health outcomes for people living
with HIV, and reducing HIV related health disparities.
At the local level HIV and AIDS prevention efforts are also a work in progress.
According to Mr. Sullivan, “the Men’s Soul Food Project is the only African American HIV
prevention project in Sacramento for African-American MSM’s and the first since the mid-80’s”
(Pulai, Annabella, 2003, para. 2). The program works to provide information on HIV and AIDS,
Barriers to Human Immunodeficiency Virus Prevention and Care 14
risk prevention strategies, and a place to meet for the gay African American male and MSM
community.
Educational: African Americans statistically have lower graduation rates than other
ethnic groups. According to Gamboa, (2012) on average only 47% of African American males
graduate from High School in four years, compared to Caucasian males who graduate at a rate of
78% in four years. Lack of education amongst the African American community is correlated to
higher rates of HIV. Lack of health education in schools is also a contributing factor to increased
rates of HIV. California law does not require schools to teach sexual education, but if they do
decide to participate in sexual education they must abide by strict guidelines (National Coalition
to Support Sexuality Education-Default Home Page, n.d.). These factors contribute to the fact
that gay African American males and MSM, now account for most new infections of HIV among
African Americans (CDC, 2014, December 10). Enforcing that public schools teach health
education in their classrooms and not restricting their guidelines, would allow public institutions
the ability to inform students about the proper use of contraception, specifically condoms.
Education on how to properly use contraception, as well as insights into the risks of not using
contraception, can lower the rate of HIV among gay African American male students or MSM
(CDC, 2014, December 10).
In the United States only 22 out of 50 states are mandated to provide some form of health
education and out of those 22 states, only 2 teach their students about HIV education (Sex and
HIV Education, 2015, March 1). Only 8 states require that their education program provide
instruction on health education that is not biased towards any race, sex or ethnicity (Sex and HIV
Education, 2015). The lack of health education in certain states or restriction on HIV education
makes efforts to reduce HIV amongst the gay and MSM African American males difficult. If
Barriers to Human Immunodeficiency Virus Prevention and Care 15
young gay African American men and MSM are not learning about HIV education in the public
school system, HIV cases between the age group of 13-24 will continue to increase (CDC, 2014,
December 10).
Environmental: Maintaining a healthy environment is an important factor for sustaining
a high quality of life (Healthy People, 2015, April 15a). People spend most of their time at
home, work, or school, so maintaining healthy homes and communities is essential to living a
healthier life (Healthy People, 2015, April 15b). Residential segregation and ongoing poverty
have left African Americans living in some of the lowest resourced communities in America
(Algernon 2013, July 22). People living in environments with higher levels of poverty
experience more social and behavioral problems (Algernon 2013, July 22). Additionally,
poverty can limit access to health care and HIV testing (CDC, 2013, June 25a). People living
below the poverty line are twice as likely to be infected with HIV in comparison to people living
in that same community, but are living above the poverty line (CDC, 2013, June 25b). With a
higher percentage of African Americans living in high poverty communities, their risk of
exposure to HIV increases (CDC, 2013, June 25c).
In communities where you find poverty you also find crime, which is tied to violence and
drug use (Berrebi, 2013). African American males living in communities with a high level of
poverty have a higher probability of being incarcerated, simply due to environmental exposure.
Higher poverty leads to higher rates of violence and crimes that lead to more African Americans
being incarcerated. Incarceration places African American gay males and MSM in an unsafe
environment that can lead to unsafe sex and rape against inmates. High levels of unsafe sex and
rape within prisons has been a leading cause of the increased rates of HIV among the African
American community (CDC, 2014, December 8).
Barriers to Human Immunodeficiency Virus Prevention and Care 16
Cultural Considerations: As America approaches its third decade since the AIDS
epidemic began, rates of new cases remain completely disproportionate among African
Americans and continue to increase more rapidly as compared to other ethnic groups. The
stigma around HIV and AIDS makes it extremely hard for those living with this disease to seek
help, especially gay African American males and MSM. Gay African American men are less
likely than other gay men and MSM to be aware of their HIV status. This in turn can exasperate
the spread of disease, creating more incidence of late diagnoses and treatment.
The stigma gay African American men and MSM are facing, results in many levels of
discrimination and prejudice from the community, many times resulting in social isolation
(Overstreet et al., 2013). HIV positive gay African American men and MSM, may be dealing
with at least three co-occurring stigmatizations from being HIV-positive. First and foremost, this
group is a racial minority, up against racism from the community, as well as lack of acceptance
from the gay community. Second, gay African American men and MSM represent a sexual
minority as well, subsequently, they are also not accepted in the black community. Finally, these
men may be of low socioeconomic status in addition to their sexual orientation or sexual
preference, resulting in the additional burden to combat with throughout life (Overstreet,
Earnshaw, Kalichman, & Quinn, 2013).
Misconceptions about HIV and mode of transmission may be at the root of the problem,
as to why judgment of those who are gay or MSM and HIV positive occurs. Anti-gay activists
Herek, & Capitanio, (1999) maintain that “It’s safe to say AIDS is the first and greatest by-
product of the Gay Liberation Movement.” This argument is a reflection of how many people
associate gay individuals directly with the AIDS epidemic, and completely forgo the large
contribution compulsive drug users lend to the spread of HIV as well.
Barriers to Human Immunodeficiency Virus Prevention and Care 17
African Americans have historically dealt with oppression and unfair treatment from
society due to racism. Rejection within the black community occurs often for those who are gay
or MSM, because homophobia is very strong among this community (Overstreet et al., 2013).
The diverse, yet interrelated levels of discrimination faced by gay African American men and
MSM creates a hovering sense of disconnectedness, especially when seeking medical attention.
The medical community contributes to the long history of abuse towards African Americans,
which in turn has affected the trust these individuals have towards the medical community
(Malebranche, 2011). For example, in the Tuskegee syphilis study, doctors took advantage of
399 impoverished black men with syphilis over a 40 year long experiment to see how the disease
would progress, during which time, the men were given no cure (About the USPHS Syphilis
Study, n.d.). The unethical nature of this study, along with many personal accounts of
discrimination concerning medical staff, has had a negative effect on African American views of
the medical system.
Due to the mistrust gay African American males or MSM have concerning the medical
community, African Americans use health services less than their Caucasian counterparts, which
further contributes to the disparities among gay African American males or MSM within the
healthcare community (Wyatt, 2009). Gay African American men and MSM are already
struggling with displacement from the gay Caucasian community for being African American, in
addition to the African American community for being gay. Now they are also dealing with a
medical system that they fear seeking help from, due to negative interactions with medical staff.
“Negative feelings such as shame concerning one’s HIV status, make it difficult for people living
with HIV and AIDS to tell others about their disease status and may impact their decision to seek
help” (Overstreet, Earnshaw, Kalichman, & Quinn, 2013).
Barriers to Human Immunodeficiency Virus Prevention and Care 18
The constant attack on gay African American males and MSM, creates stigma and drives
discrimination from the public. These realities make life tremendously difficult for gay African
American males and MSM living with HIV. This population is in dire need of help in fighting
the HIV and AIDS epidemic. Unfortunately, gay African American males and MSM who have
HIV positive status, dictate their lives and behavior choices around the stigma associated with
infection. “More importantly, these are me
n who don’t believe they have the tools, resources, role models, self-esteem, or internal fortitude
to address these issues in a positive and constructive manner.” (Malebranche, 2011).
Existing Policies, Services, and Programs
Sacramento County has a diverse array of existing policies, services and programs which
aim to address sexually transmitted disease prevention, although few are intended to work
exclusively toward HIV service access. Sacramento County’s HIV Planning Council is working
to address and implement policies to approach the needs of the community surrounding HIV
resources. As their mission statement explains, their main goals are to, “assess the needs of
people living with HIV in Sacramento County; establish appropriate service priorities; and
allocate federal grant funding of the Ryan White HIV/AIDS Treatment Modernization Act to pay
for the delivery of HIV/AIDS medical and support services for those who otherwise could not
afford such services” (HIV Health Services Planning Council, 2015, p.1). Governmental
influence could also encompass the work of Sacramento County’s Health and Human Services
Department, through the delivery of HIV and STD testing for the public, as well as specifically
for MSM and African Americans. The focus of the Health and Human Services Department is to
provide Sacramento County residents “HIV/STD prevention and risk reduction through
educational services, HIV/STD risk assessment and risk reduction counseling, HIV/STD
Barriers to Human Immunodeficiency Virus Prevention and Care 19
screening and HIV/STD trainings and workshops” (Health and Human Services (HIV/STD
Prevention Program), 2015, January 1, p. 2). On a local ZIP code basis, there does not appear to
be any specific policies in place to address HIV related issues. Small community non-profits,
such as the Sacramento LGBT Community Center, seem to do the majority of the work on an
independent basis.
This service focus area is without a hospital, but has five local health clinics. All are
sites which perform HIV testing during traditional business hours and only the Cares Community
Health Clinic performs outreach education aimed at HIV prevention within the MSM community
(California Department of Education, 2014, p.1-5). Additionally, the Sacramento LGBT
Community Center and Sunburst Projects are currently offering supportive programs which
focus on preventing new HIV infections and caring for those already living with the illness.
Current Importance to Address Issue
More can be done to bolster the existing programs within the Sacramento area. A
primary need exists to reduce the numbers of those who have unknown HIV status and provide
the treatment necessary for those with current HIV infections, that they may have the opportunity
to live longer and more productive lives. McKiernan, Bois, Alvy, & Jones address the issue on
the importance of health resource access for those at risk of HIV by noting that there were,
“proportions of HIV-negative (24%) and HIV-positive (26%) men reporting limited health care
access, whereas men who did not know their HIV status were significantly more likely to report
limited access (41%)” (2013, pg. 40). African American gay males and MSM within California
are already facing cultural, financial, societal, and health inequities. The National Coalition for
LGBT Health (2010, p. 3), described a study in which, “...an intervention program involving
HIV-related risk behavior education, self-management and sexual responsibility training, and the
Barriers to Human Immunodeficiency Virus Prevention and Care 20
fostering of supportive social networks saved almost $20,000 per participant in medical costs
averted.” Having an informed supportive community with awareness of status, access to
treatment, and an environment of support, can go far in reducing new instances of infection as
well as reducing the financial burden on publicly funded service agencies.
As the Affordable Care Act has mandated health coverage for all, the share of costs for
individuals now relies on all taxpayers. Now more than ever, the CDC’s estimate that prevention
of simply one HIV case over a lifetime saves taxpayers “$379,668 (in 2010 dollars), and
prevention and intervention is deemed cost-saving if its CE ratio is less than $379,668 per
infection averted”(CDC, 2013, p.7). This justifies the importance of HIV prevention work.
Proposal
In the Know will implement a primary intervention program called PrEP for Love, titled
in recognition of the treatment method known as pre-exposure prophylaxis. PrEP for Love will
target 75 African American males who self-identify as gay or as men who sleep with men,
between the ages of 18-24 within Sacramento County. The needs assessment identified the ZIP
codes 95811 & 95814 within the Sacramento County “Lavender Heights” district, as distinct
LGBT communities. As such, the Lavender Heights area serves as a hot bed for social gathering
among our target population and for this reason will be the center of operation for the PrEP for
Love program. With this program, In the Know strives to prevent HIV infection in the target
population through sex education and supply of the drug Truvada. The medicines within this pill
work in conjunction to prevent the HIV virus from establishing infection within an individual
when taken daily. Consistent use of the drug imparts the greatest resistance to the virus for its
user, and “has been shown to reduce the risk of HIV infection in people who are at high risk by
up to 92%” (Pre-Exposure Prophylaxis (PrEP), 2014, September 30, para. 2). Since commitment
Barriers to Human Immunodeficiency Virus Prevention and Care 21
to taking the drug once a day is vital to its performance within the body and ability to stave off
infection, the PrEP for Love program will emphasize the importance of regular use during
educational demonstrations and supply of the pill.
Beginning January 2nd 2015, In the know will commence the PrEP for Love
program. This free clinic will be hosted at the Sacramento LGBT Community Center on the first
Saturday of each month thereafter its launch date, and culminate December 3rd 2016. PrEP for
Love will allocate a 30 day supply of the drug Truvada to the first 75 African American gay or
MSM males within the age limits of 18-24, which can provide verification with a driver’s license
or parcel of mail that they reside within Sacramento County limits. In addition, applicants will
be required to submit a rapid oral HIV test which registers negative before acceptance into the
program, and each month there after so their HIV status can be recorded throughout the
year. Applicants will be terminated from the program if they contract the virus within the year,
at which point they will be referred to the Cares Community Health Clinic for HIV related
treatment options. During each monthly refill, applicants will be asked to answer a questionnaire
regarding their sexual activities for the previous month, including number of partners, use of
additional protection and type of sex performed. These 75 individuals will also be required to
present the ID card registered to them the first day of the clinic each month to receive refill of the
drug.
On January 2nd 2016 the first safe sex education class will be held at the LGBT
Community Center, where our health educators will mediate small group discussions on topics
including proper use, benefits and statistics related to Truvada as well as side effects, to aid
applicants in their decision of whether to try Truvada. Following the first safe sex education
class, topics will change focus to overall sexual education. Those 75 applicants accepted into the
Barriers to Human Immunodeficiency Virus Prevention and Care 22
program will be issued an ID card, which must be presented to receive their first 30 day
supply. The safe sex education classes will be presented on each first Saturday thereafter,
exclusively for our participants. At the end of the program, the rapid oral HIV test results along
with the questionnaire, will be used to tabulate the effectiveness of Truvada in the test group and
determine the helpfulness it rendered to its users. Additionally, before a participant may sign up
for the program, they will be required to take a pre-test concerning their knowledge of safe
sexual practices, Truvada and how they perceive their behaviors to affect their HIV risk, prior to
attending one of the safe sex education classes. At the conclusion of the program in December,
participants will be given a post-test asking similar questions, in order to track their expansion of
knowledge concerning Truvada, HIV risk and safe sexual practices, as well as rate their
satisfaction with different facets of the program.
Partner Organizations
In the Know will work closely with two organizations known to have a large proportion
of gay males and MSM for clientele within the target intervention areas of 95811 and
95814. The Sacramento LGBT Community Center, as well as the Cares Community Health
Clinic, will both serve an assisting role in the PrEP for Love Program. Cares Community Health
Clinic is committed to both contributing 75 monthly Orasure HIV tests to the PrEP for Love
Program, the Truvada medication to any medically qualifying client who wishes to follow the
drug regimen, as well as provision of the follow up care necessary for those participants
eliminated from the program due to an HIV positive test result. In the Know is committed to
maintaining an ethical continuum of care for all candidates participating in the program which
become HIV positive, and will ensure a straightforward transition to the appropriate HIV
treatment.
Barriers to Human Immunodeficiency Virus Prevention and Care 23
Additionally, given that the Sacramento LGBT Community Center maintains a long-
standing relationship with the target population, as well as physical proximity to the intervention
areas, the center has volunteered to host the recurring safe sex education classes and serve as the
Truvada re-fill clinic for the program. The Sacramento LGBT Community Center has
committed volunteers to assist with the setup and breakdown of the monthly re-fill clinic and
safe sex education classes, as well as reserve the space and ensure availability on the agreed
upon dates. To ensure that PrEP for Love health educators are aware of culturally responsive
guidelines and needs of this population, training will be given by the Center to meet this need.
Community Involvement
In the Know will work closely with the Sacramento LGBT Community Center to
promote the program to the community and boost involvement in LGBT events throughout 2015
and 2016. There are seven major LGBT events in 2015 and recurring events every 2nd Saturday
of the month. Community engagement at these events provides In the Know the opportunity to
promote the PrEP for Love program to the public, as well as gain the attention of local experts
and concerned individuals by extending an invitation to participate in the safe sex education
classes and form a discussion panel intended to gather local knowledge and concerns relevant to
HIV prevalence in the target population.
Program Planning Model
In the Know utilized the generalized planning model to provide the framework for
planning an intervention. The five basic elements of the generalized planning model are
assessing target needs, setting goals and expectations, developing interventions, implementing
interventions, and evaluating the results. In the first of the five steps we collected and analyzed
data that lead us to determine this health disparity and identify male African Americans who are
Barriers to Human Immunodeficiency Virus Prevention and Care 24
gay or MSM within the 18-24 age group, as our priority population. In the Know set goals and
objectives which identify what will be accomplished during our intervention. Third, we
developed the intervention, which is both collaborative and instructional in regards to the
provision of the medication as well as education concerning Truvada and HIV prevention
techniques, for reducing incidence of HIV transmission among our participants and to meet our
goals and objectives. Next, we put our program to action over the course of 12 months. The last
aspect of this model is the evaluation of the results. We will utilize both formative and
summative techniques, discussed later in more detail.
We will be working closely with our participants to teach them the importance of taking
Truvada daily and the risks that come along with unprotected sex. The combination of our
presence and level of involvement within the Lavender Heights District, ensure that awareness of
these issues will increase, as well as garner the attention of the target population, increasing PrEP
for Love’s chance at success and decreasing the rate of HIV transmission in the target
population.
Program Goal
1) Reduce the spread of HIV infection among 75 18-24 year old African American males
who identify as gay or men who sleep with men with in Sacramento County by
employing the use of the prescription drug, Truvada and safe sex education.
Objectives
Overall Program Objectives
1) To provide 75 African American males who identify as gay or men that sleep with men
a monthly supply of the pre-exposure prophylaxis pill known as Truvada, as well
education pertaining to its proper use, benefits and side effects.
Barriers to Human Immunodeficiency Virus Prevention and Care 25
2) During the 12 month dispersal of Truvada, all participants taking the drug will
significantly reduce their risk of contracting HIV through daily use of the drug Truvada.
Learning Objectives
1) After the first safe sex education class 75% of potential participants will be able to
identify some specific risks of contracting HIV.
2) After the first safe sex education class, all potential participants will be able to explain the
benefits and risks associated with the use of Truvada.
Behavioral Objectives
1) 95% of participants will maintain adherence to taking the 30-day supply of
Truvada each month for 12 months.
2) 75% of participants will positively promote Truvada at the end of 12 months.
3) 50% of participants will practice safer sex, beyond adherence to the proper use of
Truvada, by the end of 12 months.
Environmental Objective
1) By January 2016, PrEP for love will personally create and hang a rainbow colored PrEP
for love banner in the Lavender Heights District representing our support of the LGBT
community.
Process Objectives
1) Beginning in April 2015 through May 2015, the Sacramento LGBT Community Center
staff will have trained the health educators in how to be culturally competent in teaching
our target population.
2) From June through December 2015, program educators will visit local high schools
within Sacramento County to deliver a presentation about the PrEP of Love program.
Barriers to Human Immunodeficiency Virus Prevention and Care 26
3) From June through December 2015, program educators will promote the program at 7
major Sacramento LGBT Organization events to draw participants to the program.
4) By the start of January 2016, the program staff will have enrolled 50% of the 75 total
participants allotted.
Evaluation Matrix
Objectives Type Evaluation Measure
To provide 75 African American males who
identify as gay or men that sleep with men a
monthly supply of the pre-exposure prophylaxis
pill known as Truvada, as well education
pertaining to its proper use, benefits and side
effect.
Program
*Monthly roster of
registered ID cards
*Monthly questionnaire
*Pretest/Posttest
During the 12 month dispersal of Truvada, all
participants taking the drug will significantly
reduce their risk of contracting HIV through
daily use of the drug Truvada.
Program
*Monthly Orasure HIV
test
After the first safe sex education class at least
75% of potential participants will be able to
identify their risk of contracting HIV.
Learning
*Monthly questionnaire
*Pretest/Posttest
After the first safe sex education class, all
potential participants will be able to explain the
benefits and risks associated with the use of
Truvada.
Learning
*Monthly questionnaire
*Pretest/Posttest
At least 95% of participants will maintain
adherence to taking the 30-day supply of
Truvada each month during the 12-month
program.
Behavior
*Monthly roster of
registered ID cards
*Monthly questionnaire
By the end of the program, 50% of all
participants will practice safer sex, beyond
adherence to the proper use of Truvada.
Behavior
*Monthly questionnaire
*Pretest/Posttest
By January 2016, PrEP for love will personally
create and hang a rainbow colored PrEP for love
banner in the Lavender Heights District
representing our support of the LGBT
community.
Environmental
*Monthly questionnaire
*Pretest/Posttest
Barriers to Human Immunodeficiency Virus Prevention and Care 27
Beginning in April 2015 through May 2015, the
Sacramento LGBT Community Center staff will
have trained the health educators in how to be
culturally competent in teaching our target
population.
Process *Training confirmation
From June through December 2015, program
educators will visit local high schools within
Sacramento County to deliver a presentation
about the PrEP of Love program.
Process
*PrEP for Love Pre-
Program sign-up Sheet
From June through December 2015, program
educators will promote the program at 7 major
Sacramento LGBT Organization events to draw
participants to the program.
Process
*PrEP for Love Pre-
Program sign-up Sheet
By the start of January 2016, the program staff
will have enrolled 50% of the 75 total
participants allotted.
Process
*Pretest count
*Monthly roster of
registered ID cards
Barriers to Human Immunodeficiency Virus Prevention and Care 28
Timeline
Community
Needs
Assessment
Key
Informant
Interviews
Program
Development
Program
Marketing
Program
Pre-test
Program
Post-test
Sign-up
Period
Implement
Program
Data
Tabulation
Evaluation
2015
Jan
Feb
Mar
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
2016
Jan
Feb
Mar
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
2017
Jan
Feb
(There will be continuous enrollment throughout the 2016 year each month, until 75 participants have
been enrolled. Since participants will be enrolled and disqualified from the program throughout the entire
2016 year, pre and post tests will also be administered throughout the entire 2016 year as well.)
Barriers to Human Immunodeficiency Virus Prevention and Care 29
Evaluation
The effectiveness of our intervention and the extent to which awareness, attitudes,
knowledge, behaviors change as a result, will be measured at the conclusion of PrEP for Love
program. PrEP for love will teach risk-reduction behaviors as the foundation of the intervention
on the first Saturday of each month for 12 months. These safe sex education classes will consist
of topics including sexual risks, HIV stigma, disclosure of HIV status, health care and self-care.
Our 75 participants will be divided into 5 groups of 15 during safe sex education classes to
discuss these topics with the guidance of our health educators. Participants will have the option
to take the pre-exposure prophylaxis drug Truvada, once pre-approved for the treatment.
Participants taking Truvada will also be questioned within the monthly questionnaire regarding
their adherence to taking Truvada during the 12 month intervention.
A formative evaluation approach is necessary to assess the quality of the program by
using mixed-methods to collect data. Our findings will inform stakeholders regarding the
benefits of PrEP for Love, as well as provide our lead internal evaluator Cassandra Sammons
with ideas to improve program implementation. Participants will be required to take a monthly
questionnaire regarding their sex practices the previous month, adherence to taking Truvada and
knowledge based questions to assess the effectiveness of the safe sex education classes. Our
health educators Taylor Lewis, Diane Myers, Vincent Landers and Jacob Alas, will lead the
monthly safe sex education classes and distribute monthly questionnaires. These questionnaires
will be compared to track improvements in knowledge, reduction in risk taking behaviors,
adherence to taking Truvada, and to provide support for program improvements. The
questionnaire will inquire about specifics such as the number of partners, types of protection
Barriers to Human Immunodeficiency Virus Prevention and Care 30
used, and the type of sex performed. Additionally, monthly oral HIV tests will be administered
to track each participants HIV status.
Informal interviews will be conducted by our health educators to acquire qualitative data
during our safe sex education classes. Our health educators will encourage participants to
support one another when sharing personal experiences related to sexual risk, HIV stigma, and
disclosure of HIV status in a confidential, and respectful atmosphere. Direct observation will be
performed by Cassandra Sammons, in which she will assess the interactions between instructors
and participants and the behavior of participants. The data derived during the formative
evaluation will measure the quality of the program and direct any revisions to the program.
Impact evaluations and outcome evaluations will be assessed at the conclusion of the program to
provide a conclusive statement regarding program effects. Results of the summative evaluation
will be valued by all stakeholders in relation to PrEP for Love that include those involved in the
program operations, and those served and affected by the program.
A non-experimental pre-test-post-test design will be used during the program. A pre-test
will be administered concerning their knowledge of safe sexual practices, Truvada and how they
perceive their behaviors to affect their HIV risk. The pre-test will be given prior to the first safe
sex education class. A subsequent post-test will be administered during the last safe sex
education class, which will be compared to the pre-test to assess participants as to whether they
have gained or retained any knowledge of HIV risks, safe sex practices, and the benefits along
with their satisfaction concerning Truvada. Both HIV negative and positive results will be
tabulated along with the participation rate.
PrEP for Love evaluation results are important to the program staff, participants, partners,
and funders. Our staff will anticipate different sets of questions that various stakeholders would
Barriers to Human Immunodeficiency Virus Prevention and Care 31
have based on their own particular interests. We will also stress the different aspects of the
evaluation results based on the varying interests between stakeholders. We will share our data
with potential funding sources interested in learning about the program’s success. Our staff will
lead a power point presentation including graphs to display where the program succeeded and
was lacking, for funders to evaluate the the program. We also plan to share our findings with our
partners, the Sacramento LGBT Community Center and the Cares Community Health Clinic, in
order to increase community support. Positive evaluation data will be distributed via the proper
communication channel, to generate backing for PrEP for Love and the possibility of future
funding.
Organizational Capacity
Program Manager: Cassandra Sammons
Cassandra graduated from San Jose State University with a Bachelor’s Degree in Health
Science with concentration in Health Care Administration. She then obtained her Master’s in
Health Care Administration from California State University Northridge. Cassandra has 7 years
of experience working as a program manager, and is currently working with the American Heart
Association to direct a new program aimed at lowering cholesterol in adults over the age of 35.
Cassandra volunteered at the Billy DeFrank Lesbian and Gay Community Center in San Jose and
worked with health educators to decrease HIV levels in San Jose. Her dedication to lowering
HIV rates among the gay community will help our program reach its goals.
Health Educators
Taylor Lewis
Taylor Lewis received her Bachelor’s Degree in Health Education from California State
University Long Beach. She has worked with many non-profit organizations and institutions to
Barriers to Human Immunodeficiency Virus Prevention and Care 32
help promote safe sex, as well as presenting at high schools and community colleges on topics
related to STI prevention.
Diane Myers
Diane Myers received her Bachelors in Health Education from California State
University Sacramento. She currently works as a part time employee for Sacramento State as a
health educator and is responsible for providing students with information on STI transmission
and human anatomy.
Vincent Landers
Vincent Landers graduated from San Jose University with a degree in Health Science
with concentration in Community Health. Vincent has experience working with Planned
Parenthood in their outreach and education department.
Jacob Alas
Jacob Alas is a health educator with a Bachelor’s Degree in Health Education from
Arizona State University. Jacob works with the Sacramento Unified School District to provide
health education at local high schools, and has been working with the Sacramento Unified
School District for over 10 years.
Administrative Assistant: Lucy Vale
Lucy Vale graduated from California State University Sacramento with her Bachelor’s
degree in Business Administration, and has worked with many organizations as an administrative
assistant. Lucy also worked at the Sacramento Health and Human Services Department and for
the research and development department at UC Davis medical center.
Barriers to Human Immunodeficiency Virus Prevention and Care 33
Risk Analysis
In The Know has taken many preparatory steps to address any issues that may arise
during the course of this project, as well as ensuring that continued care for our participants is
transferred to the Cares Clinic at the conclusion of the program. In the Know is proud to be
jointly collaborating with Cares Community Health and the Sacramento LGBT Community
Center to meet our objectives and possible concerns. The PrEP for Love program intends to
focus on creating sexual health and wellness, in addition to ensuring an HIV negative status
through use of the drug Truvada in community participants, as well as building lasting
connections to services provided by our agency partners.
In The Know intends to create long-term linkages with our partner organizations, by
utilizing the services of the Sacramento LGBT Community Center’s Certified Enrollment
Counselors, which will help provide enrollment assistance to any uninsured participant. As a
result, the Center will receive funding through Covered California or Medi-Cal, based on their
enrollment efforts on behalf of this important work. The Center is providing space for In the
Knows five groups of fifteen, as well as the provision of volunteers to assist in the set-up and
break down involved within the space at no cost to the program. The Center has volunteered
with the additional intent to help bolster its lack of groups which are geared toward MSM
African Americans. PrEP for Love will provide bus vouchers to participants whom request
them. Conveniently, the Sacramento LGBT Community Center is located along a busy bus route
and this will help any individual who may be concerned with transportation needs.
Additionally, all newly insured or participants wishing to receive Cares Community
Health’s donated Truvada medications, will be required to become Cares Community Health
Center patients, as the time involved to monitor each client will be provided by in-kind donation
Barriers to Human Immunodeficiency Virus Prevention and Care 34
of provider time. It is important that participants are covered with insurance as well as have a
provider who can follow their ongoing care needs, and have the opportunity for medications to
be covered by insurance at the conclusion of the PrEP for Love Program. Should any participant
have a positive HIV result, a Cares Community Health personnel will administer a whole blood
HIV test. A subsequent positive result will immediately disqualify the participant, and their
continued care will then be transferred to the Cares Community Health Clinic for HAART
treatment and intervention.
In The Know is dedicated to providing quality and culturally responsive sexual health
treatment and education to participants. To ensure PrEP for Love’s health educators and project
leaders are aware of this community’s special needs, the Sacramento LGBT Community Center
will be providing in-kind and donated cultural competency training with a focus on the MSM
population. The small group sexual health education structure is modeled after the best practices
from recommendations provided by the American Medical Association’s curriculum. This
curriculum includes topics pertaining to Gay and Bisexual health, to ensure that our health
educators are knowledgeable and that quality education is conveyed adequately to our
participants. The use of a questionnaire will be utilized at every meeting to ensure learning can
be objectively measured as an outcome. If the PrEP for Love program leaders notice a decline in
scores from the questionnaire, steps will be taken to address this issue by meeting with our health
educators to determine the course of action.
Participants in the PrEP for Love program have a minimum time requirement of an hour
and a half a month as well as the cost of moderate emotional energy to participate. This will
ensure that the PrEP for Love program responsibly educates community members, ensures
negative HIV statuses and responsible program delivery, as well as prescription refills for
Barriers to Human Immunodeficiency Virus Prevention and Care 35
participants who choose to opt for Truvada medication intervention. Additionally, the group
setting ensures that a sense of community is fostered as well as an opportunity to form bonds and
support. Participants are guaranteed bus vouchers, social support, a safe space for sexual health
education, as well as access to Truvada, should their Cares provider agree it is an appropriate
intervention for them to utilize.
In the Know intends to utilize strong partnerships with Cares and the Sacramento LGBT
Community Center to create solutions and work through the challenges and obstacles that arise
in a responsive and community focused approach. Bi-weekly meetings will be held at the In the
Know office to discuss current issues and to have opportunities for collaborative work. Both of
In the Knows partners are able to receive compensation for the work they are doing as well as
participate in creating access to care solutions for this at risk population. This collaboration
intends to replicate the successful work done in the Castro District of San Francisco in 2012
which sought to provide the same level of education, lower new cases of HIV in the city and
guarantee easy access to the PrEP medication for those who qualified. Follow up care for the
PrEP for Love Program will be enveloped by the Cares Community Health Clinic through their
outreach program at the conclusion of the program. The Center intends to continue hosting the
MSM groups to ensure a sense of community. Much benefit is anticipated overall from
taxpayers in California to lower our rates of new HIV cases in the African American MSM
population, to improve access to preventative care and increase utilization of existing services.
Barriers to Human Immunodeficiency Virus Prevention and Care 36
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http://www.cdc.gov/hiv/prevention/research/prep/
Pulai, A. (2003). The men’s soul food project feeds the needs of SGL men of African
descent. Outward Magazine, 16. Retrieved from www.outwardmagazine.com
Sacramento County Main Jail (1999). Final Report Internet Version. Retrieved from
http://www.sacgrandjury.org/reports/98-99/gjury98-99-14.asp
Sacramento Pride. (n.d.). About Sacramento Pride. Retrieved from
https://www.sacramentopride.org/about.shtml
Sex and HIV Education. (2015, March 1). Retrieved March 7, 2015, from
http://www.guttmacher.org/statecenter/spibs/spib_SE.pdf
Sood, N., Juday, T., Vanderpuye-Orgle, J., Rosenblatt, L., Romley, J., et al. (2014). HIV
Care providers emphasize the importance of the Ryan White program for access to and
quality of care. Health Affairs, 33(3), 394-400.
Barriers to Human Immunodeficiency Virus Prevention and Care 41
Statistics-San Francisco AIDS Foundation. (n.d.). Retrieved from http://sfaf.org/hiv-info/
statistics/
The Affordable Care Act and HIV/AIDS. (2014). Retrieved from
https://aids.gov/federal-resources/policies/health-care-reform/
Understanding Disparities in the HIV Epidemic. (n.d.). Retrieved February 12, 2015, from
http://www.advocatesforyouth.org/publications/publications-a-z/524-understanding-
disparities-in-the-hiv-epidemic-
Wyatt, G. E. (2009). Enhancing Cultural and Contextual Intervention Strategies to Reduce
HIV/AIDS Among African Americans. American Journal of Public Health, 99(11),
1941–1945. doi:10.2105/AJPH.2008.152181
Barriers to Human Immunodeficiency Virus Prevention and Care 42
Appendices
Marketing
Product
In the Knows’ PrEP for Love Program primarily focuses on the delivery of safe sex
education, distribution of the medication Truvada and outreach to educate the at risk population
and inform them of services available to help them avoid HIV infection.
Promotion
In the Know will utilize Facebook, Instagram, and Twitter to advertise the program to
local residents. The popularity of social media, as well as its convenience as a tool that may be
accessed anytime, make it an ideal approach for promotion of the program. Our health educators
will also make appearances at all of the major Sacramento LGBT Community Center events,
namely the Sacramento Pride Parade, Pride awards and Red dress party. In the Know will have a
booth at the Sacramento LGBT Community Center’s healthcare event “Take Pride in Your
Health Fair,” along with other organizations to publicize the PrEP for Love Program by passing
out informational brochures detailing the program. This specific event offers free HIV testing
and health screenings, which are benefits in line with what the PrEP for Love Program will
provide as well. Our four health educators will also coordinate with local high schools to speak
about the PrEP for Love program and its benefits to encourage of age participants to enroll and
inform underage students about resources they may utilize in the future.
Place
The provision of an accommodating and tranquil environment for our participants each
time they attend a monthly session will be provided by the Sacramento LGBT Community
Center in downtown Sacramento at no cost to the program. Additionally, one of our major
Barriers to Human Immunodeficiency Virus Prevention and Care 43
program partners, the Cares Community Health Clinic, is conveniently located just 7 minutes
away from the Sacramento LGBT Community Center. Our disqualified participants will be
referred to the CARES Clinic for health related services following a positive HIV test result.
Price
Our participants will be expected to attend all 1 ½ hour safe sex education classes and
adhere to taking Truvada daily if the participant has opted to do so. Aside from maintain prompt
attendance, we also encourage participants to share their personal experiences related sex and
HIV or AIDS during our class sessions, however this is not mandatory due to the sensitivity of
our program.
Barriers to Human Immunodeficiency Virus Prevention and Care 44
Line Item Budget
Proposal
Expenses
Total Project Budget Request to the California Endowment
1st
Year
2nd
Year
3rd
Year
(2
months)
Total
1st
Year
2nd
Year
3rd
Year (2
months)
Total
Personnel
Program
Manager
(0.25 FTE)
$30,500 $30,500 $5,083 $66,083 $24,400 $24,400 $4,066 $52,866
Health
Educator
(4 @ 0.50)
$112,000
($28,000
each)
$112,000
$37,332
($9,333
each)
$261,332 $89,600 $89,600 $29,864 $209,064
Admin
Assistant
(0.10 FTE)
$4,000 $4,000 $666 $8,666 $3,200 $3,200 $532 $6,832
Benefits/
Taxes 25%
$36,625 $36,625 $40,162 $113,412 $35,400 $35,400 $8,615 $79,415
Total
Personnel
$183,125 $183,125 $83,243 $449,493 $152,600 $152,600 $43,077 $348,177
Non-Personnel
Office Supplies $1,783 $1,783 $297 $3,863 $1,426 $1,426 $237 $3,089
Travel $1,153 $1,153 $192 $2,498 $922 $922 $153 $1,997
Postage $230 $230 $38 $498 $184 $184 $30 $398
Meeting Costs
(in kind)
$0 $0 $0 $0 $0 $0 $0 $0
Equipment
(in kind)
$0 $0 $0 $0 $0 $0 $0 $0
Advertising
(in kind)
$0 $0 $0 $0 $0 $0 $0 $0
Total non-
personnel
$3,166 $3,166 $527 $6,859 $2,532 $2,532 $420 $5,484
Grand
Total
$186,291 $186,291 $83,770 $456,352 $155,132 $155,132 $43,497 $353,661
Barriers to Human Immunodeficiency Virus Prevention and Care 45
Budget Narrative
Program Manager
Direct program operations, advertising, monitor the budget, approve expenditures,
structure the PrEP for Love monthly Truvada refill days and alternative pick up days for
emergency’s and no shows and coordinate with partner organizations. Additionally, the program
manager will organize the safe sex education classes, assist health educators prepare pre-tests
and post-tests, monthly questionnaires and educational materials for the monthly safe sex
education class.
Health Educators
Will lead and deliver safe sex education classes, develop and present PrEP for Love
program information at our community outreach events and recruit program participants from
local Sacramento County High Schools and Sacramento LGBT Community Center Events.
Administrative Assistant
Create and maintain filing of participant pre/post tests and monthly questionnaires, as
well as tabulate participant attendance for each monthly pickup and support other staff.
Volunteers
Volunteers from the Sacramento LGBT Community Center will be responsible for the set
up and breakdown of the PrEP for Love safe sex education classes, refill station for participants
to pick up their monthly supply of Truvada and the distribution of condoms and lube during the
classes. Volunteers will create the flyers and posters used to promote safe sex and the PrEP for
Love program at local Sacramento County high schools and Sacramento LGBT Community
Center events.
Barriers to Human Immunodeficiency Virus Prevention and Care 46
Non-personnel
Office Supplies
Includes a printer, printer toner, paper, two staplers and staples, pens, pencils,
highlighters and filing folders. A Xerox WorkCentre 6505 dn color multifunction printer will
cost $574.95, and will be used for all organizational printing needs such as fliers, pre and post
surveys, questionnaires, contracts, financial statements, etc. Printer toner and 5,000 sheets of
paper will cost roughly $2895.74 and $91.98 respectively, for the complete duration of the
program. Pens, pencils, highlighters, staplers and staples and folders will be purchased for
$302.21, for the entire program.
Meeting costs
The Sacramento LGBT Community Center has agreed to host the PrEP for Love Program
for its duration at no cost. This includes seating, tables and volunteers from the community
center to set up and break down safe sex education classes and the Truvada check in and pick up
station.
Equipment
The Cares Community Health Clinic will contribute 75 monthly Orasure HIV tests to the
PrEP for Love Program as well as any personal protective equipment needed for administering
the test, such as gloves. Gilead Pharmaceuticals will donate the monthly allotment of 75 bottles
of Truvada for 12 months, totaling 900 bottles of Truvada during the program.
Travel
In the Know will provide daily bus pass vouchers for in-need individuals, up to $2,500.
Postage
An allotment of $500 will be available for postage.
Barriers to Human Immunodeficiency Virus Prevention and Care 47
Advertising
In the Know will market the PrEP for Love Program for free at local Sacramento County
High Schools and Sacramento LGBT Community Center events. Fliers and informational
brochures will be printed by In the Know and mailed to potential participants and/or participants
and passed out during LGBT events; the cost for this is covered under postage and office
supplies.

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Proposal Assignment

  • 1. Barriers to Human Immunodeficiency Virus Prevention and Care Barriers to HIV/AIDS Prevention and Care for Gay and MSM African American Males 18-24 Rene’ Walling, Elena Costa, Jennifer Manibot, Ronn Gonzales, Esther Campos and Esmeralda Mendoza California State University Sacramento 144-02
  • 2. Barriers to Human Immunodeficiency Virus Prevention and Care 2 Acknowledgement To complete this grant assignment, we gratefully accepted the help and guidance of some revered persons, who deserve our sincere appreciation. We acknowledge our gratitude of Dr. Diaz, professor with the California State University, Sacramento, for providing us with guidance through the development of this grant, clarification of numerous questions, and for assistance navigating comprehensive written instructions. Additionally, we thank all who supported us explicitly in our work as well as those who did so indirectly. A great deal of individuals supported us, from our direct teammates to our fellow classmates, whom offered suggestions that led to direct improvements to this project.
  • 3. Barriers to Human Immunodeficiency Virus Prevention and Care 3 Abstract Within Sacramento County, disproportionately high numbers of African American males are contracting HIV infection each year. Historically African Americans struggled with oppression, unequitable treatment from society due to racism, and a tendency to utilize healthcare services at far lower rates than other ethnic groups. Research explains that the gay and MSM community, regardless of ethnic group, tend to utilize health services far less overall, due to mistrust of medical service providers. Now that the Affordable Care act has built bridges to treatment and care, ensuring linkages are available to all, the time to act is now to create opportunities for access to care for this high risk group. The cost of even one case of HIV over the course of a lifetime in both emotional, physical and financial burdens is one that society has a responsibility to address. In the Know will create access to care for gay African American males and MSM in Sacramento County by way of the PrEP for Love Program. PrEP for Love focuses on reducing HIV infection by use of sexual health information, easy access to the pre-exposure prophylactic medication Truvada, linkage to culturally responsive health providers for long-term care, and assistance with obtaining health insurance coverage as needed. To ensure that PrEP for Love utilizes a complete and thorough approach to reducing area infection rates, In the Know sought out input from a similar project in San Francisco, California. Their approach with both sexual health education and access to PrEP was so successful, they had zero cases of HIV infection during the life cycle of the project. In the Know intends to replicate their work and utilize partnerships with area service providers to reach 75 participants over the course of twenty-six months. This innovative approach to provide access to care will reduce the overall burden of cost of new HIV patients, empower the MSM community, and provide safer sex education.
  • 4. Barriers to Human Immunodeficiency Virus Prevention and Care 4 TABLE OF CONTENTS ACKNOWLEDGEMENTS…………………………………………………………………...…….....2 ABSTRACT…………………………………………………………………………………..…......3 TABLE OF CONTENTS…..……………………………………………………...……...………......4 STATEMENT OF PROBLEM…..………………………………………………………...……….….6 TARGET POPULATION…………………………………………………………………………….7 DATA/INFORMATION NATIONAL..……………………………………………………………………………......7 STATE…..…………………………………………………….…………………………....8 LOCAL…..………………………………………………………………………………....9 UNDERSTANDING OF PROBLEM SOCIAL....……………………………………………………………………..…..……...11 POLITICAL…..………..…………………………………………………………..………12 EDUCATIONAL……………………………………………………………………………14 ENVIRONMENTAL…..…………………………………………………………………….15 CULTURAL CONSIDERATIONS…..………………...……………………………………...16 POLICY EXISTING POLICIES, SERVICES AND PROGRAMS…..……………………..………………18 CURRENT IMPORTANCE TO ADDRESS ISSUE……………………………………………..19 PROPOSAL DETAILS OF PROPOSAL………………………………………………………………..…20 PARTNER ORGANIZATIONS………………………………………………………………22 COMMUNITY INVOLVEMENT…………………………………………………………….23 PROGRAM PLANNING MODEL……………………………………………………………23
  • 5. Barriers to Human Immunodeficiency Virus Prevention and Care 5 PROGRAM GOALS & OBJECTIVES PROGRAM GOALS…………………………………………………………………………24 OVER ALL PROGRAM OBJECTIVES………………………………………………………..24 LEARNING OBJECTIVES…………………………………………………………………...25 BEHAVIORAL OBJECTIVES………………………………………………………………...25 ENVIRONMENTAL OBJECTIVES…………………………………………………………...26 PROCESS OBJECTIVES……………………………………………………………………..26 EVALUATION MATRIX…………………………………………………………………………...26 TIMELINE………………………………………………………………………………………...28 EVALUATION…………………………………………………………………………………….29 ORGANIZATIONAL CAPACITY…………………………………………………………………...31 RISK ANALYSIS…………………………………………………………………………………..33 REFERENCES………….…..………………………………..………...…………………………..36 APPENDICES MARKETING……………………………………………………………………………….42 LINE ITEM BUDGET………………………………………………………………..………44 BUDGET NARRATIVE………………………………………………………………………45
  • 6. Barriers to Human Immunodeficiency Virus Prevention and Care 6 Statement of Problem HIV infection rates among Sacramento County men of color, namely African American men who identify as gay or as men who sleep with men, (MSM) are rising. Sacramento County ranks 8out of the 58 counties within California for cases of HIV, this is of serious concern and must be addressed to impede the infection rate of HIV in Sacramento County (Office of AIDS, 2014). The Centers of Disease Control (2014, p.2) explain, “gay, bisexual, and other men who have sex with men, particularly young black/African American MSM, are most seriously affected by HIV.” Youth are the individuals who are at highest risk for new HIV infection. The CDC also highlights, “in 2010, the estimated number of new HIV infections was highest among individuals aged 25-34, followed by individuals aged 13-24” (2014, p.2). Many factors are at play concerning this trend of rising HIV infections, however, it is clear that access to care is at the forefront of the issue. “Nearly a quarter of African-American and Latino families live in poverty, which can limit access to HIV testing and medical care. Homophobia and HIV stigma, far too common in all communities, can discourage individuals from seeking HIV testing, prevention and treatment services. Other barriers to HIV testing and care include discrimination, unstable housing and low rates of health insurance coverage” (CDC, 2014, p.9). Health insurance coverage, along with engagement in regular visits to a medical provider, are vital components to link individuals to the preventative health services necessary to care for chronic issues, as well as health education in general. Research by McKiernan, D., Bois, S., Alvy, L., & Jones, K., (2013, p. 40) uncovered that those who exclusively identified as MSM and were also African American, “had reduced access as compared with Caucasians, that income was positively related to access, which are consistent with the trends reported among the general population.”
  • 7. Barriers to Human Immunodeficiency Virus Prevention and Care 7 Target Population The target population is African American males who self-identify as gay or as MSM, between the ages of 18-24. The target location is Sacramento County, in the city of Sacramento, CA, specifically the ZIP codes 95811 & 95814 in the midtown area. Data/Information National: The Centers for Disease Control and Prevention indicate that, “more than 1.2 million people in the United States are living with HIV infection and almost 1 in 7 (14%) are unaware of their infection” (CDC, 2014, November 25, para. 1). Men who identify as gay, bisexual, and MSM who are young black and African American, are most seriously affected by HIV. From 2008 to 2010, “the greatest number of HIV infections was among MSM aged 13 to 24, and teen African Americans continue to bear a disproportionate number of new HIV infections” (CDC, 2014, November 25, para. 3). Young gay African American males between the ages 13-24, who are involved in gay sex, have the highest estimated total of new HIV infections (4,800). “This group also accounts for 45% of the new HIV infections among gay African American men and MSM, as well as 55% of the new HIV infections among young MSM overall” (CDC, 2014, November 25, para. 9). The much smaller rate of 21% of new HIV infections is among Hispanics and Latinos in 2010; this comparison highlights the urgency with which the high rates among African Americans need to be addressed (CDC, 2014, November 25, para. 19). According to the Centers for Disease Control and Prevention, “since the epidemic began, an estimated 265,812 African Americans with AIDS diagnosis have died, including an estimated 6,630 in 2011” (CDC, 2014, November 25, para. 10). The organization also states that “unless the course of HIV infection in the United States changes at some point in their lifetime, an
  • 8. Barriers to Human Immunodeficiency Virus Prevention and Care 8 estimated 1 in 16 African American men and 1 in 32 African American women will be diagnosed with HIV infection” (CDC, 2014, November 25, para.14). Furthermore, statistical data from 2010 indicated that “75% of HIV-infected African Americans aged 13 or older are linked to care, 48% are retained in care, 46% are prescribed antiretroviral therapy, and only 35% are virally suppressed” (CDC, 2014, December 8, para. 10). The CDC (2005, June 22) also mentions a study on prevalence within groups of African American males, which found upon close of inspection of the rates in the United States among five major cities, nearly 50% of all gay African American men and bisexual men were HIV-positive, additionally the number of people living with HIV has increased, while the annual number of new HIV infections has remained relatively stable. The facts that the CDC provides are validations that the target population needs some kind of support in order to suppress the issue. Existing governmental policies should be reviewed in order to help the people involved in this matter. State: According to the California Department of Public Health (2014), cumulative HIV and AIDS cases in California, total 18,434 for African Americans (4,589 HIV cases and 13,845 AIDS cases) that were exposed through gay sexual activity. In addition to this, the California Department of Public Health (2014) also reports that approximately 70% of all newly HIV infected African Americans were exposed through MSM activity and injection drug use. In 2011 the total estimate of adults and adolescents diagnosed with HIV due to MSM activity in California in 2011 was 78.3%, with 20% of these cases occurring in African American males (California Department of Public Health, 2014). The San Francisco Aids Foundation calculates that about 134,158 people are living with HIV in California (Statistics-San Francisco AIDS Foundation, n.d.). The AIDS incidence rate per 100,000 population among African Americans in the state of California is three times higher than the rate for Caucasians and Latinos in 2006,
  • 9. Barriers to Human Immunodeficiency Virus Prevention and Care 9 32.35/100,000 versus 9.6/100,000 and 9.67/100,000, respectively (California Department of Public Health, 2014, June 30). Lastly, HIV is also being largely transmitted within hostile environments, such as county jails and prisons. The Bureau of Justice reports in their 2001 statistics bulletin, that in 1999, California ranked 4th for the highest number of AIDS cases in United States prisons in (Bureau of Justice Statistics Bulletin, 1999). The Sacramento Court Grand Jury report states that, “HIV positive inmates are not required to be segregated from other prisoners during their time in prison” (Sacramento County Main Jail, 1999, para 5). It is a known fact that blood borne diseases can be easily spread in aggressive environments like prisons. Policies and procedures are needed to protect inmates and decrease the spread of AIDS within local and federal prisons. Local: The prevalence of AIDS and HIV in Sacramento County should be of enormous concern. According to the California Department of Public Health, (2014, June 6) Sacramento County ranks in the top 10 cities for HIV and AIDS. This is especially accurate for the combined ZIP codes of 95811 and 95814, which have had the highest amassed cases of AIDS among the County of Sacramento, from 1982 to 2007 (County of Sacramento Quarterly AIDS Report, 2008). According to National HIV Testing Day, (2009, June 27) from the County of Sacramento’s Department of Health and Human Services, African Americans represented 22% of reported cases, all though they only made up 11% of Sacramento County’s population. The California Department of Public Health’s semiannual report (2014, June 30) indicates that Sacramento has a total of 1627 HIV cases, 1545 living cases and 82 (5%) deceased. The Sacramento Pride organization (n.d.) reports that the City of Sacramento is estimated to have a gay population of 9.8%, the sixth highest in the nation and more than the national average of 4.1%. The Pride Institute is the organization responsible for managing the
  • 10. Barriers to Human Immunodeficiency Virus Prevention and Care 10 Sacramento Pride Parade that is held in ZIP codes 95814 and 95811. The Sacramento Gay Pride Parade is known as one of the largest sources of funding for programs and services at the LGBT community center in Sacramento. The LGBT center provides HIV and AIDS testing, transgender support and other activities that serve the community (Sacramento Pride, n.d.). The Lavender Heights District is also located within the Sacramento ZIP 95811. The Lavender heights District is a place known for its high numbers of gay-owned businesses. Ron Jones of CBS Sacramento, (2014, December 15) declares that local community activists are making a push in midtown to honor the LGBT community and affiliated businesses to promote the gay community. Local activists are also pushing that the nickname “Lavender Heights” be made the official title of the area. Advocates would also like to include custom made street signs and rainbow-colored cross walks and flags throughout the area (Jones, 2014). These realities validate the activity of the LGBT community in our focus area and the need for assistance in improving all aspects of a gay lifestyle, including equal access to healthcare. The Sacramento Department of Health and Human Services (2015a) reports that ZIP code 95814 has only two HIV testing sites. Sharing syringes for injection drug use is one major pathway for the spread of blood borne diseases. As of April 2014, there are two pharmacies that participate in the “non-prescription sale of syringes” in the ZIP codes 95814 and 95811. People who are actively using syringes for illegal drug use are more likely to share if they do not have access to new ones. When this happens, HIV and AIDS, as well as other diseases can be easily passed from person to person, in addition to sexual partners (Department of Health and Human Services, 2015b). This issue is clearly related to healthcare access and currently impacts this populations chance to avoid HIV transmission via syringe, additionally, not having proper access
  • 11. Barriers to Human Immunodeficiency Virus Prevention and Care 11 to health care increases the risk of death among African Americans, once diagnosed with AIDS (HIV & AIDS Among African Americans, n.d.). Understanding of Problem Social: The plight of all African Americans dates back to the infamous early days of slavery, however the strong sense of inequality and racism displayed by affluent Caucasian slaveholders and communities alike, has burned its negative influence into the minds of preceding and present generations. The stark reality is, simply being African American is a strong indication that HIV infection will occur. Inequalities within the African American community demonstrate why social influences have such a negative impact upon disease infection and poor treatment outcomes. The social implications are apparent in the high rates of unemployment, incarceration, drug use and lack of education among African Americans, to name just a few. It is a common misconception that gay men are somehow more affluent and well off than their heterosexual counterparts. According to the Bureau of Labor Statistics, the overall unemployment rate for the Unites States in 2013 was 7.4%, alarmingly, for this same year the rate is almost double for African Americans at 13.1% (Bureau of Labor Statistics, 2014). Not surprisingly, the average income of African Americans is also comparatively low, even for those able to acquire employment. For 2013, the U.S. Census Bureau (2014) states that the median income for the United States was $51,939; African American households earned nearly 30% less, with a median income of $34,598 (DeNavas-Walt, & Proctor, 2014). Additionally African American gay men and MSM may struggle with feelings of discrimination from the medical community. The combination of low income and reluctance to seek medical care leaves many vulnerable to infection and lack of care for ongoing conditions, such as aids (Moyer, 2011).
  • 12. Barriers to Human Immunodeficiency Virus Prevention and Care 12 The isolation is further exemplified by “the widespread perception of high HIV prevalence among the African American community, which in turn increases the stigma and discrimination that members of the community who are living with HIV experience” (HIV & AIDS Among African Americans | AVERT. n.d., para. 47). These disparities within our communities, increase the likelihood of African American MSM choosing sexual partners within their race, thus concentrating the already high prevalence of HIV further within African American society (HIV & AIDS Among African Americans | AVERT. n.d.). The stigma associated with homosexuality is also a contributing factor to the high rate of HIV/AIDS among African American MSM. Many prioritize keeping their status as a gay man secretive, forgoing the medical treatment needed for associated STI’s and HIV/AIDS treatment and screening. Those who live in poverty are also less likely to have access to medical treatment and may go longer periods of time either unaware they are infected with HIV or an STI, or without treatment for it (Understanding Disparities in the HIV Epidemic, n.d.). Societal pressures influence and promote the emotional stress that result in risk taking health behaviors and the HIV epidemic among young African American MSM (between the ages of 13 and 24) in the USA (HIV & AIDS Among African Americans | AVERT. n.d.). Political: According to HIV & AIDS Among African Americans, (n.d.) not having proper access to health care increases the risk of dying among African Americans, once diagnosed with AIDS. Compared to other racial and ethnic groups, the risk of contracting HIV is also higher among African Americans (The Affordable Care Act and HIV/AIDS, 2014). One of the very first programs that has contributed to improving healthcare access is the Ryan White Program, enacted in 1990. Health care providers agree that this program has provided high- quality care for those affected with the disease (Sood, Juday, Vanderpuve-Orgle, Rosenblatt,
  • 13. Barriers to Human Immunodeficiency Virus Prevention and Care 13 Romley, et al., 2014). Medical care for HIV is financially demanding, and serves as a barrier to care for many ethnic minorities, such as African Americans. In the article, “HIV Care Providers Emphasize the Importance of The Ryan White Program for Access to and Quality of Care,” HIV patients are described as, “poor with unstable living conditions, are uninsured or-underinsured” (Sood, Juday, Vanderpuve-Orgle, Rosenblatt, Romley, et al., 2014, para. 2). Before the Affordable Care Act (Obama Care) was implemented on March 23, 2010, access to health care remained an obstacle for those infected with HIV and AIDS, despite implementation of previous programs. Today Obama Care ensures coverage for preventive services like HIV testing, lowered medical costs, expanded Medicaid coverage, provides more affordable private health coverage, and ensured coverage for people with pre-existing conditions (The Affordable Care Act and HIV/AIDS, 2014). Before this triumph in the healthcare system, anyone with a pre-existing health condition like HIV and AIDS could be denied coverage or care. HIV and AIDS patients no longer have to fear the possibility of being denied care. In collaboration with the Affordable Care Act, the National HIV/AIDS Strategy released on July 13, 2010 by President Obama, has made efforts to research, prevent, and treat HIV (The Affordable Care Act and HIV/AIDS, 2014). Goals for the strategy include but are not limited to, reducing HIV infections, increasing access to care, improving health outcomes for people living with HIV, and reducing HIV related health disparities. At the local level HIV and AIDS prevention efforts are also a work in progress. According to Mr. Sullivan, “the Men’s Soul Food Project is the only African American HIV prevention project in Sacramento for African-American MSM’s and the first since the mid-80’s” (Pulai, Annabella, 2003, para. 2). The program works to provide information on HIV and AIDS,
  • 14. Barriers to Human Immunodeficiency Virus Prevention and Care 14 risk prevention strategies, and a place to meet for the gay African American male and MSM community. Educational: African Americans statistically have lower graduation rates than other ethnic groups. According to Gamboa, (2012) on average only 47% of African American males graduate from High School in four years, compared to Caucasian males who graduate at a rate of 78% in four years. Lack of education amongst the African American community is correlated to higher rates of HIV. Lack of health education in schools is also a contributing factor to increased rates of HIV. California law does not require schools to teach sexual education, but if they do decide to participate in sexual education they must abide by strict guidelines (National Coalition to Support Sexuality Education-Default Home Page, n.d.). These factors contribute to the fact that gay African American males and MSM, now account for most new infections of HIV among African Americans (CDC, 2014, December 10). Enforcing that public schools teach health education in their classrooms and not restricting their guidelines, would allow public institutions the ability to inform students about the proper use of contraception, specifically condoms. Education on how to properly use contraception, as well as insights into the risks of not using contraception, can lower the rate of HIV among gay African American male students or MSM (CDC, 2014, December 10). In the United States only 22 out of 50 states are mandated to provide some form of health education and out of those 22 states, only 2 teach their students about HIV education (Sex and HIV Education, 2015, March 1). Only 8 states require that their education program provide instruction on health education that is not biased towards any race, sex or ethnicity (Sex and HIV Education, 2015). The lack of health education in certain states or restriction on HIV education makes efforts to reduce HIV amongst the gay and MSM African American males difficult. If
  • 15. Barriers to Human Immunodeficiency Virus Prevention and Care 15 young gay African American men and MSM are not learning about HIV education in the public school system, HIV cases between the age group of 13-24 will continue to increase (CDC, 2014, December 10). Environmental: Maintaining a healthy environment is an important factor for sustaining a high quality of life (Healthy People, 2015, April 15a). People spend most of their time at home, work, or school, so maintaining healthy homes and communities is essential to living a healthier life (Healthy People, 2015, April 15b). Residential segregation and ongoing poverty have left African Americans living in some of the lowest resourced communities in America (Algernon 2013, July 22). People living in environments with higher levels of poverty experience more social and behavioral problems (Algernon 2013, July 22). Additionally, poverty can limit access to health care and HIV testing (CDC, 2013, June 25a). People living below the poverty line are twice as likely to be infected with HIV in comparison to people living in that same community, but are living above the poverty line (CDC, 2013, June 25b). With a higher percentage of African Americans living in high poverty communities, their risk of exposure to HIV increases (CDC, 2013, June 25c). In communities where you find poverty you also find crime, which is tied to violence and drug use (Berrebi, 2013). African American males living in communities with a high level of poverty have a higher probability of being incarcerated, simply due to environmental exposure. Higher poverty leads to higher rates of violence and crimes that lead to more African Americans being incarcerated. Incarceration places African American gay males and MSM in an unsafe environment that can lead to unsafe sex and rape against inmates. High levels of unsafe sex and rape within prisons has been a leading cause of the increased rates of HIV among the African American community (CDC, 2014, December 8).
  • 16. Barriers to Human Immunodeficiency Virus Prevention and Care 16 Cultural Considerations: As America approaches its third decade since the AIDS epidemic began, rates of new cases remain completely disproportionate among African Americans and continue to increase more rapidly as compared to other ethnic groups. The stigma around HIV and AIDS makes it extremely hard for those living with this disease to seek help, especially gay African American males and MSM. Gay African American men are less likely than other gay men and MSM to be aware of their HIV status. This in turn can exasperate the spread of disease, creating more incidence of late diagnoses and treatment. The stigma gay African American men and MSM are facing, results in many levels of discrimination and prejudice from the community, many times resulting in social isolation (Overstreet et al., 2013). HIV positive gay African American men and MSM, may be dealing with at least three co-occurring stigmatizations from being HIV-positive. First and foremost, this group is a racial minority, up against racism from the community, as well as lack of acceptance from the gay community. Second, gay African American men and MSM represent a sexual minority as well, subsequently, they are also not accepted in the black community. Finally, these men may be of low socioeconomic status in addition to their sexual orientation or sexual preference, resulting in the additional burden to combat with throughout life (Overstreet, Earnshaw, Kalichman, & Quinn, 2013). Misconceptions about HIV and mode of transmission may be at the root of the problem, as to why judgment of those who are gay or MSM and HIV positive occurs. Anti-gay activists Herek, & Capitanio, (1999) maintain that “It’s safe to say AIDS is the first and greatest by- product of the Gay Liberation Movement.” This argument is a reflection of how many people associate gay individuals directly with the AIDS epidemic, and completely forgo the large contribution compulsive drug users lend to the spread of HIV as well.
  • 17. Barriers to Human Immunodeficiency Virus Prevention and Care 17 African Americans have historically dealt with oppression and unfair treatment from society due to racism. Rejection within the black community occurs often for those who are gay or MSM, because homophobia is very strong among this community (Overstreet et al., 2013). The diverse, yet interrelated levels of discrimination faced by gay African American men and MSM creates a hovering sense of disconnectedness, especially when seeking medical attention. The medical community contributes to the long history of abuse towards African Americans, which in turn has affected the trust these individuals have towards the medical community (Malebranche, 2011). For example, in the Tuskegee syphilis study, doctors took advantage of 399 impoverished black men with syphilis over a 40 year long experiment to see how the disease would progress, during which time, the men were given no cure (About the USPHS Syphilis Study, n.d.). The unethical nature of this study, along with many personal accounts of discrimination concerning medical staff, has had a negative effect on African American views of the medical system. Due to the mistrust gay African American males or MSM have concerning the medical community, African Americans use health services less than their Caucasian counterparts, which further contributes to the disparities among gay African American males or MSM within the healthcare community (Wyatt, 2009). Gay African American men and MSM are already struggling with displacement from the gay Caucasian community for being African American, in addition to the African American community for being gay. Now they are also dealing with a medical system that they fear seeking help from, due to negative interactions with medical staff. “Negative feelings such as shame concerning one’s HIV status, make it difficult for people living with HIV and AIDS to tell others about their disease status and may impact their decision to seek help” (Overstreet, Earnshaw, Kalichman, & Quinn, 2013).
  • 18. Barriers to Human Immunodeficiency Virus Prevention and Care 18 The constant attack on gay African American males and MSM, creates stigma and drives discrimination from the public. These realities make life tremendously difficult for gay African American males and MSM living with HIV. This population is in dire need of help in fighting the HIV and AIDS epidemic. Unfortunately, gay African American males and MSM who have HIV positive status, dictate their lives and behavior choices around the stigma associated with infection. “More importantly, these are me n who don’t believe they have the tools, resources, role models, self-esteem, or internal fortitude to address these issues in a positive and constructive manner.” (Malebranche, 2011). Existing Policies, Services, and Programs Sacramento County has a diverse array of existing policies, services and programs which aim to address sexually transmitted disease prevention, although few are intended to work exclusively toward HIV service access. Sacramento County’s HIV Planning Council is working to address and implement policies to approach the needs of the community surrounding HIV resources. As their mission statement explains, their main goals are to, “assess the needs of people living with HIV in Sacramento County; establish appropriate service priorities; and allocate federal grant funding of the Ryan White HIV/AIDS Treatment Modernization Act to pay for the delivery of HIV/AIDS medical and support services for those who otherwise could not afford such services” (HIV Health Services Planning Council, 2015, p.1). Governmental influence could also encompass the work of Sacramento County’s Health and Human Services Department, through the delivery of HIV and STD testing for the public, as well as specifically for MSM and African Americans. The focus of the Health and Human Services Department is to provide Sacramento County residents “HIV/STD prevention and risk reduction through educational services, HIV/STD risk assessment and risk reduction counseling, HIV/STD
  • 19. Barriers to Human Immunodeficiency Virus Prevention and Care 19 screening and HIV/STD trainings and workshops” (Health and Human Services (HIV/STD Prevention Program), 2015, January 1, p. 2). On a local ZIP code basis, there does not appear to be any specific policies in place to address HIV related issues. Small community non-profits, such as the Sacramento LGBT Community Center, seem to do the majority of the work on an independent basis. This service focus area is without a hospital, but has five local health clinics. All are sites which perform HIV testing during traditional business hours and only the Cares Community Health Clinic performs outreach education aimed at HIV prevention within the MSM community (California Department of Education, 2014, p.1-5). Additionally, the Sacramento LGBT Community Center and Sunburst Projects are currently offering supportive programs which focus on preventing new HIV infections and caring for those already living with the illness. Current Importance to Address Issue More can be done to bolster the existing programs within the Sacramento area. A primary need exists to reduce the numbers of those who have unknown HIV status and provide the treatment necessary for those with current HIV infections, that they may have the opportunity to live longer and more productive lives. McKiernan, Bois, Alvy, & Jones address the issue on the importance of health resource access for those at risk of HIV by noting that there were, “proportions of HIV-negative (24%) and HIV-positive (26%) men reporting limited health care access, whereas men who did not know their HIV status were significantly more likely to report limited access (41%)” (2013, pg. 40). African American gay males and MSM within California are already facing cultural, financial, societal, and health inequities. The National Coalition for LGBT Health (2010, p. 3), described a study in which, “...an intervention program involving HIV-related risk behavior education, self-management and sexual responsibility training, and the
  • 20. Barriers to Human Immunodeficiency Virus Prevention and Care 20 fostering of supportive social networks saved almost $20,000 per participant in medical costs averted.” Having an informed supportive community with awareness of status, access to treatment, and an environment of support, can go far in reducing new instances of infection as well as reducing the financial burden on publicly funded service agencies. As the Affordable Care Act has mandated health coverage for all, the share of costs for individuals now relies on all taxpayers. Now more than ever, the CDC’s estimate that prevention of simply one HIV case over a lifetime saves taxpayers “$379,668 (in 2010 dollars), and prevention and intervention is deemed cost-saving if its CE ratio is less than $379,668 per infection averted”(CDC, 2013, p.7). This justifies the importance of HIV prevention work. Proposal In the Know will implement a primary intervention program called PrEP for Love, titled in recognition of the treatment method known as pre-exposure prophylaxis. PrEP for Love will target 75 African American males who self-identify as gay or as men who sleep with men, between the ages of 18-24 within Sacramento County. The needs assessment identified the ZIP codes 95811 & 95814 within the Sacramento County “Lavender Heights” district, as distinct LGBT communities. As such, the Lavender Heights area serves as a hot bed for social gathering among our target population and for this reason will be the center of operation for the PrEP for Love program. With this program, In the Know strives to prevent HIV infection in the target population through sex education and supply of the drug Truvada. The medicines within this pill work in conjunction to prevent the HIV virus from establishing infection within an individual when taken daily. Consistent use of the drug imparts the greatest resistance to the virus for its user, and “has been shown to reduce the risk of HIV infection in people who are at high risk by up to 92%” (Pre-Exposure Prophylaxis (PrEP), 2014, September 30, para. 2). Since commitment
  • 21. Barriers to Human Immunodeficiency Virus Prevention and Care 21 to taking the drug once a day is vital to its performance within the body and ability to stave off infection, the PrEP for Love program will emphasize the importance of regular use during educational demonstrations and supply of the pill. Beginning January 2nd 2015, In the know will commence the PrEP for Love program. This free clinic will be hosted at the Sacramento LGBT Community Center on the first Saturday of each month thereafter its launch date, and culminate December 3rd 2016. PrEP for Love will allocate a 30 day supply of the drug Truvada to the first 75 African American gay or MSM males within the age limits of 18-24, which can provide verification with a driver’s license or parcel of mail that they reside within Sacramento County limits. In addition, applicants will be required to submit a rapid oral HIV test which registers negative before acceptance into the program, and each month there after so their HIV status can be recorded throughout the year. Applicants will be terminated from the program if they contract the virus within the year, at which point they will be referred to the Cares Community Health Clinic for HIV related treatment options. During each monthly refill, applicants will be asked to answer a questionnaire regarding their sexual activities for the previous month, including number of partners, use of additional protection and type of sex performed. These 75 individuals will also be required to present the ID card registered to them the first day of the clinic each month to receive refill of the drug. On January 2nd 2016 the first safe sex education class will be held at the LGBT Community Center, where our health educators will mediate small group discussions on topics including proper use, benefits and statistics related to Truvada as well as side effects, to aid applicants in their decision of whether to try Truvada. Following the first safe sex education class, topics will change focus to overall sexual education. Those 75 applicants accepted into the
  • 22. Barriers to Human Immunodeficiency Virus Prevention and Care 22 program will be issued an ID card, which must be presented to receive their first 30 day supply. The safe sex education classes will be presented on each first Saturday thereafter, exclusively for our participants. At the end of the program, the rapid oral HIV test results along with the questionnaire, will be used to tabulate the effectiveness of Truvada in the test group and determine the helpfulness it rendered to its users. Additionally, before a participant may sign up for the program, they will be required to take a pre-test concerning their knowledge of safe sexual practices, Truvada and how they perceive their behaviors to affect their HIV risk, prior to attending one of the safe sex education classes. At the conclusion of the program in December, participants will be given a post-test asking similar questions, in order to track their expansion of knowledge concerning Truvada, HIV risk and safe sexual practices, as well as rate their satisfaction with different facets of the program. Partner Organizations In the Know will work closely with two organizations known to have a large proportion of gay males and MSM for clientele within the target intervention areas of 95811 and 95814. The Sacramento LGBT Community Center, as well as the Cares Community Health Clinic, will both serve an assisting role in the PrEP for Love Program. Cares Community Health Clinic is committed to both contributing 75 monthly Orasure HIV tests to the PrEP for Love Program, the Truvada medication to any medically qualifying client who wishes to follow the drug regimen, as well as provision of the follow up care necessary for those participants eliminated from the program due to an HIV positive test result. In the Know is committed to maintaining an ethical continuum of care for all candidates participating in the program which become HIV positive, and will ensure a straightforward transition to the appropriate HIV treatment.
  • 23. Barriers to Human Immunodeficiency Virus Prevention and Care 23 Additionally, given that the Sacramento LGBT Community Center maintains a long- standing relationship with the target population, as well as physical proximity to the intervention areas, the center has volunteered to host the recurring safe sex education classes and serve as the Truvada re-fill clinic for the program. The Sacramento LGBT Community Center has committed volunteers to assist with the setup and breakdown of the monthly re-fill clinic and safe sex education classes, as well as reserve the space and ensure availability on the agreed upon dates. To ensure that PrEP for Love health educators are aware of culturally responsive guidelines and needs of this population, training will be given by the Center to meet this need. Community Involvement In the Know will work closely with the Sacramento LGBT Community Center to promote the program to the community and boost involvement in LGBT events throughout 2015 and 2016. There are seven major LGBT events in 2015 and recurring events every 2nd Saturday of the month. Community engagement at these events provides In the Know the opportunity to promote the PrEP for Love program to the public, as well as gain the attention of local experts and concerned individuals by extending an invitation to participate in the safe sex education classes and form a discussion panel intended to gather local knowledge and concerns relevant to HIV prevalence in the target population. Program Planning Model In the Know utilized the generalized planning model to provide the framework for planning an intervention. The five basic elements of the generalized planning model are assessing target needs, setting goals and expectations, developing interventions, implementing interventions, and evaluating the results. In the first of the five steps we collected and analyzed data that lead us to determine this health disparity and identify male African Americans who are
  • 24. Barriers to Human Immunodeficiency Virus Prevention and Care 24 gay or MSM within the 18-24 age group, as our priority population. In the Know set goals and objectives which identify what will be accomplished during our intervention. Third, we developed the intervention, which is both collaborative and instructional in regards to the provision of the medication as well as education concerning Truvada and HIV prevention techniques, for reducing incidence of HIV transmission among our participants and to meet our goals and objectives. Next, we put our program to action over the course of 12 months. The last aspect of this model is the evaluation of the results. We will utilize both formative and summative techniques, discussed later in more detail. We will be working closely with our participants to teach them the importance of taking Truvada daily and the risks that come along with unprotected sex. The combination of our presence and level of involvement within the Lavender Heights District, ensure that awareness of these issues will increase, as well as garner the attention of the target population, increasing PrEP for Love’s chance at success and decreasing the rate of HIV transmission in the target population. Program Goal 1) Reduce the spread of HIV infection among 75 18-24 year old African American males who identify as gay or men who sleep with men with in Sacramento County by employing the use of the prescription drug, Truvada and safe sex education. Objectives Overall Program Objectives 1) To provide 75 African American males who identify as gay or men that sleep with men a monthly supply of the pre-exposure prophylaxis pill known as Truvada, as well education pertaining to its proper use, benefits and side effects.
  • 25. Barriers to Human Immunodeficiency Virus Prevention and Care 25 2) During the 12 month dispersal of Truvada, all participants taking the drug will significantly reduce their risk of contracting HIV through daily use of the drug Truvada. Learning Objectives 1) After the first safe sex education class 75% of potential participants will be able to identify some specific risks of contracting HIV. 2) After the first safe sex education class, all potential participants will be able to explain the benefits and risks associated with the use of Truvada. Behavioral Objectives 1) 95% of participants will maintain adherence to taking the 30-day supply of Truvada each month for 12 months. 2) 75% of participants will positively promote Truvada at the end of 12 months. 3) 50% of participants will practice safer sex, beyond adherence to the proper use of Truvada, by the end of 12 months. Environmental Objective 1) By January 2016, PrEP for love will personally create and hang a rainbow colored PrEP for love banner in the Lavender Heights District representing our support of the LGBT community. Process Objectives 1) Beginning in April 2015 through May 2015, the Sacramento LGBT Community Center staff will have trained the health educators in how to be culturally competent in teaching our target population. 2) From June through December 2015, program educators will visit local high schools within Sacramento County to deliver a presentation about the PrEP of Love program.
  • 26. Barriers to Human Immunodeficiency Virus Prevention and Care 26 3) From June through December 2015, program educators will promote the program at 7 major Sacramento LGBT Organization events to draw participants to the program. 4) By the start of January 2016, the program staff will have enrolled 50% of the 75 total participants allotted. Evaluation Matrix Objectives Type Evaluation Measure To provide 75 African American males who identify as gay or men that sleep with men a monthly supply of the pre-exposure prophylaxis pill known as Truvada, as well education pertaining to its proper use, benefits and side effect. Program *Monthly roster of registered ID cards *Monthly questionnaire *Pretest/Posttest During the 12 month dispersal of Truvada, all participants taking the drug will significantly reduce their risk of contracting HIV through daily use of the drug Truvada. Program *Monthly Orasure HIV test After the first safe sex education class at least 75% of potential participants will be able to identify their risk of contracting HIV. Learning *Monthly questionnaire *Pretest/Posttest After the first safe sex education class, all potential participants will be able to explain the benefits and risks associated with the use of Truvada. Learning *Monthly questionnaire *Pretest/Posttest At least 95% of participants will maintain adherence to taking the 30-day supply of Truvada each month during the 12-month program. Behavior *Monthly roster of registered ID cards *Monthly questionnaire By the end of the program, 50% of all participants will practice safer sex, beyond adherence to the proper use of Truvada. Behavior *Monthly questionnaire *Pretest/Posttest By January 2016, PrEP for love will personally create and hang a rainbow colored PrEP for love banner in the Lavender Heights District representing our support of the LGBT community. Environmental *Monthly questionnaire *Pretest/Posttest
  • 27. Barriers to Human Immunodeficiency Virus Prevention and Care 27 Beginning in April 2015 through May 2015, the Sacramento LGBT Community Center staff will have trained the health educators in how to be culturally competent in teaching our target population. Process *Training confirmation From June through December 2015, program educators will visit local high schools within Sacramento County to deliver a presentation about the PrEP of Love program. Process *PrEP for Love Pre- Program sign-up Sheet From June through December 2015, program educators will promote the program at 7 major Sacramento LGBT Organization events to draw participants to the program. Process *PrEP for Love Pre- Program sign-up Sheet By the start of January 2016, the program staff will have enrolled 50% of the 75 total participants allotted. Process *Pretest count *Monthly roster of registered ID cards
  • 28. Barriers to Human Immunodeficiency Virus Prevention and Care 28 Timeline Community Needs Assessment Key Informant Interviews Program Development Program Marketing Program Pre-test Program Post-test Sign-up Period Implement Program Data Tabulation Evaluation 2015 Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec 2016 Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec 2017 Jan Feb (There will be continuous enrollment throughout the 2016 year each month, until 75 participants have been enrolled. Since participants will be enrolled and disqualified from the program throughout the entire 2016 year, pre and post tests will also be administered throughout the entire 2016 year as well.)
  • 29. Barriers to Human Immunodeficiency Virus Prevention and Care 29 Evaluation The effectiveness of our intervention and the extent to which awareness, attitudes, knowledge, behaviors change as a result, will be measured at the conclusion of PrEP for Love program. PrEP for love will teach risk-reduction behaviors as the foundation of the intervention on the first Saturday of each month for 12 months. These safe sex education classes will consist of topics including sexual risks, HIV stigma, disclosure of HIV status, health care and self-care. Our 75 participants will be divided into 5 groups of 15 during safe sex education classes to discuss these topics with the guidance of our health educators. Participants will have the option to take the pre-exposure prophylaxis drug Truvada, once pre-approved for the treatment. Participants taking Truvada will also be questioned within the monthly questionnaire regarding their adherence to taking Truvada during the 12 month intervention. A formative evaluation approach is necessary to assess the quality of the program by using mixed-methods to collect data. Our findings will inform stakeholders regarding the benefits of PrEP for Love, as well as provide our lead internal evaluator Cassandra Sammons with ideas to improve program implementation. Participants will be required to take a monthly questionnaire regarding their sex practices the previous month, adherence to taking Truvada and knowledge based questions to assess the effectiveness of the safe sex education classes. Our health educators Taylor Lewis, Diane Myers, Vincent Landers and Jacob Alas, will lead the monthly safe sex education classes and distribute monthly questionnaires. These questionnaires will be compared to track improvements in knowledge, reduction in risk taking behaviors, adherence to taking Truvada, and to provide support for program improvements. The questionnaire will inquire about specifics such as the number of partners, types of protection
  • 30. Barriers to Human Immunodeficiency Virus Prevention and Care 30 used, and the type of sex performed. Additionally, monthly oral HIV tests will be administered to track each participants HIV status. Informal interviews will be conducted by our health educators to acquire qualitative data during our safe sex education classes. Our health educators will encourage participants to support one another when sharing personal experiences related to sexual risk, HIV stigma, and disclosure of HIV status in a confidential, and respectful atmosphere. Direct observation will be performed by Cassandra Sammons, in which she will assess the interactions between instructors and participants and the behavior of participants. The data derived during the formative evaluation will measure the quality of the program and direct any revisions to the program. Impact evaluations and outcome evaluations will be assessed at the conclusion of the program to provide a conclusive statement regarding program effects. Results of the summative evaluation will be valued by all stakeholders in relation to PrEP for Love that include those involved in the program operations, and those served and affected by the program. A non-experimental pre-test-post-test design will be used during the program. A pre-test will be administered concerning their knowledge of safe sexual practices, Truvada and how they perceive their behaviors to affect their HIV risk. The pre-test will be given prior to the first safe sex education class. A subsequent post-test will be administered during the last safe sex education class, which will be compared to the pre-test to assess participants as to whether they have gained or retained any knowledge of HIV risks, safe sex practices, and the benefits along with their satisfaction concerning Truvada. Both HIV negative and positive results will be tabulated along with the participation rate. PrEP for Love evaluation results are important to the program staff, participants, partners, and funders. Our staff will anticipate different sets of questions that various stakeholders would
  • 31. Barriers to Human Immunodeficiency Virus Prevention and Care 31 have based on their own particular interests. We will also stress the different aspects of the evaluation results based on the varying interests between stakeholders. We will share our data with potential funding sources interested in learning about the program’s success. Our staff will lead a power point presentation including graphs to display where the program succeeded and was lacking, for funders to evaluate the the program. We also plan to share our findings with our partners, the Sacramento LGBT Community Center and the Cares Community Health Clinic, in order to increase community support. Positive evaluation data will be distributed via the proper communication channel, to generate backing for PrEP for Love and the possibility of future funding. Organizational Capacity Program Manager: Cassandra Sammons Cassandra graduated from San Jose State University with a Bachelor’s Degree in Health Science with concentration in Health Care Administration. She then obtained her Master’s in Health Care Administration from California State University Northridge. Cassandra has 7 years of experience working as a program manager, and is currently working with the American Heart Association to direct a new program aimed at lowering cholesterol in adults over the age of 35. Cassandra volunteered at the Billy DeFrank Lesbian and Gay Community Center in San Jose and worked with health educators to decrease HIV levels in San Jose. Her dedication to lowering HIV rates among the gay community will help our program reach its goals. Health Educators Taylor Lewis Taylor Lewis received her Bachelor’s Degree in Health Education from California State University Long Beach. She has worked with many non-profit organizations and institutions to
  • 32. Barriers to Human Immunodeficiency Virus Prevention and Care 32 help promote safe sex, as well as presenting at high schools and community colleges on topics related to STI prevention. Diane Myers Diane Myers received her Bachelors in Health Education from California State University Sacramento. She currently works as a part time employee for Sacramento State as a health educator and is responsible for providing students with information on STI transmission and human anatomy. Vincent Landers Vincent Landers graduated from San Jose University with a degree in Health Science with concentration in Community Health. Vincent has experience working with Planned Parenthood in their outreach and education department. Jacob Alas Jacob Alas is a health educator with a Bachelor’s Degree in Health Education from Arizona State University. Jacob works with the Sacramento Unified School District to provide health education at local high schools, and has been working with the Sacramento Unified School District for over 10 years. Administrative Assistant: Lucy Vale Lucy Vale graduated from California State University Sacramento with her Bachelor’s degree in Business Administration, and has worked with many organizations as an administrative assistant. Lucy also worked at the Sacramento Health and Human Services Department and for the research and development department at UC Davis medical center.
  • 33. Barriers to Human Immunodeficiency Virus Prevention and Care 33 Risk Analysis In The Know has taken many preparatory steps to address any issues that may arise during the course of this project, as well as ensuring that continued care for our participants is transferred to the Cares Clinic at the conclusion of the program. In the Know is proud to be jointly collaborating with Cares Community Health and the Sacramento LGBT Community Center to meet our objectives and possible concerns. The PrEP for Love program intends to focus on creating sexual health and wellness, in addition to ensuring an HIV negative status through use of the drug Truvada in community participants, as well as building lasting connections to services provided by our agency partners. In The Know intends to create long-term linkages with our partner organizations, by utilizing the services of the Sacramento LGBT Community Center’s Certified Enrollment Counselors, which will help provide enrollment assistance to any uninsured participant. As a result, the Center will receive funding through Covered California or Medi-Cal, based on their enrollment efforts on behalf of this important work. The Center is providing space for In the Knows five groups of fifteen, as well as the provision of volunteers to assist in the set-up and break down involved within the space at no cost to the program. The Center has volunteered with the additional intent to help bolster its lack of groups which are geared toward MSM African Americans. PrEP for Love will provide bus vouchers to participants whom request them. Conveniently, the Sacramento LGBT Community Center is located along a busy bus route and this will help any individual who may be concerned with transportation needs. Additionally, all newly insured or participants wishing to receive Cares Community Health’s donated Truvada medications, will be required to become Cares Community Health Center patients, as the time involved to monitor each client will be provided by in-kind donation
  • 34. Barriers to Human Immunodeficiency Virus Prevention and Care 34 of provider time. It is important that participants are covered with insurance as well as have a provider who can follow their ongoing care needs, and have the opportunity for medications to be covered by insurance at the conclusion of the PrEP for Love Program. Should any participant have a positive HIV result, a Cares Community Health personnel will administer a whole blood HIV test. A subsequent positive result will immediately disqualify the participant, and their continued care will then be transferred to the Cares Community Health Clinic for HAART treatment and intervention. In The Know is dedicated to providing quality and culturally responsive sexual health treatment and education to participants. To ensure PrEP for Love’s health educators and project leaders are aware of this community’s special needs, the Sacramento LGBT Community Center will be providing in-kind and donated cultural competency training with a focus on the MSM population. The small group sexual health education structure is modeled after the best practices from recommendations provided by the American Medical Association’s curriculum. This curriculum includes topics pertaining to Gay and Bisexual health, to ensure that our health educators are knowledgeable and that quality education is conveyed adequately to our participants. The use of a questionnaire will be utilized at every meeting to ensure learning can be objectively measured as an outcome. If the PrEP for Love program leaders notice a decline in scores from the questionnaire, steps will be taken to address this issue by meeting with our health educators to determine the course of action. Participants in the PrEP for Love program have a minimum time requirement of an hour and a half a month as well as the cost of moderate emotional energy to participate. This will ensure that the PrEP for Love program responsibly educates community members, ensures negative HIV statuses and responsible program delivery, as well as prescription refills for
  • 35. Barriers to Human Immunodeficiency Virus Prevention and Care 35 participants who choose to opt for Truvada medication intervention. Additionally, the group setting ensures that a sense of community is fostered as well as an opportunity to form bonds and support. Participants are guaranteed bus vouchers, social support, a safe space for sexual health education, as well as access to Truvada, should their Cares provider agree it is an appropriate intervention for them to utilize. In the Know intends to utilize strong partnerships with Cares and the Sacramento LGBT Community Center to create solutions and work through the challenges and obstacles that arise in a responsive and community focused approach. Bi-weekly meetings will be held at the In the Know office to discuss current issues and to have opportunities for collaborative work. Both of In the Knows partners are able to receive compensation for the work they are doing as well as participate in creating access to care solutions for this at risk population. This collaboration intends to replicate the successful work done in the Castro District of San Francisco in 2012 which sought to provide the same level of education, lower new cases of HIV in the city and guarantee easy access to the PrEP medication for those who qualified. Follow up care for the PrEP for Love Program will be enveloped by the Cares Community Health Clinic through their outreach program at the conclusion of the program. The Center intends to continue hosting the MSM groups to ensure a sense of community. Much benefit is anticipated overall from taxpayers in California to lower our rates of new HIV cases in the African American MSM population, to improve access to preventative care and increase utilization of existing services.
  • 36. Barriers to Human Immunodeficiency Virus Prevention and Care 36 References About the USPHS Syphilis Study. (n.d.). Retrieved from http://www.tuskegee.edu/about_us /centers_of_excellence/bioethics_center/about_the_usphs_syphilis_study.aspx Algernon, A. (2013, July 22). African Americans are Still Concentrated in Neighborhoods with High Poverty and Still Lack Full Access to Decent Housing. Retrieved April 20, 2015, from http://www.epi.org/publication/african-americans-concentrated-neighborhoods/ Bureau of Labor Statistics. (2014). Labor Force Characteristics by Race and Ethnicity. Retrieved from U.S. Bureau of Labor Statistics website: http://www.bls.gov/opub/ reports/cps/race_ethnicity_2013.pdf Bureau of Justice Statistics Bulletin (1999). HIV in Prisons and Jails. Retrieved from http://www.bjs.gov/content/pub/pdf/hivpj99.pdf California Department of Education. (2014, August 22). Sacramento County Sexual Health Resources. Retrieved April 20, 2015 from http://www.cde.ca.gov/ls/he/se/ sactoresources.asp California Department of Public Health. (2014). Office of AIDS. Retrieved March 4, 2015, from http://www.cdph.ca.gov/programs/aids/Pages/Default.aspx California Department of Public Health. (2014, June 6). Aids Cases in California Quarterly Report. Retrieved From http://www.cdph.ca.gov/programs/aids/Documents/June_2014 _SemiAnnualReport.pdf California Department of Public Health. (2014, June 30). HIV/AIDS Surveillance in California. Retrieved from http://www.cdph.ca.gov/programs/aids/Documents/ June_2014_SemiAnnualReport.pdf
  • 37. Barriers to Human Immunodeficiency Virus Prevention and Care 37 Centers for Disease Control and Prevention. (2005, June 22) HIV Prevalence, Unrecognized Infection, and HIV Testing Among Men Who Have Sex with Men - Five U.S. Cities, June 2004-April 2005. MMWR Weekly 54(24); 597-601. Centers for Disease Control and Prevention. (2013, April 16). HIV Cost- effectiveness. Retrieved April 20, 2015 from http://www.cdc.gov/hiv/prevention /ongoing/costeffectiveness/ Centers for Disease Control and Prevention (2013, July 15). Retrieved April 20, 2015, from http://www.cdc.gov/nchhstp/newsroom/HIVFactSheets/Epidemic/Factors.htm Centers for Disease Control and Prevention. (2014). HIV Surveillance Report. 17(3). Retrieved from http://www.cdc.gov/hiv/pdf/statistics_hssr_vol_17_no_4.pdf Centers for Disease Control and Prevention. (2014, May 29) The Care and Prevention in the United States (CAPUS) Demonstration Project. Retrieved April 20, 2015 from http://www.cdc.gov/hiv/prevention/demonstration/capus/ Centers for Disease Control and Prevention. (2014, September 24). US Public Health Service Syphilis Study at Tuskegee. Retrieved from http://www.cdc.gov/tuskegee /timeline.htm Centers for Disease Control and Prevention. (2014, November 25). HIV in the United States: At a Glance. Retrieved March 6, 2015, from http://www.cdc.gov/hiv/statistics/basics/ataglance.html Centers for Disease Control and Prevention. (2014, December 8). HIV Among African American Gay and Bisexual Men. Retrieved from http://www.cdc.gov/hiv/risk/racialethnic/bmsm/facts/index.html
  • 38. Barriers to Human Immunodeficiency Virus Prevention and Care 38 Centers for Disease Control and Prevention. (2014, December 10). HIV Among African Americans. Retrieved from http://www.cdc.gov/hiv/risk/racialethnic/aa/facts /index.html County of Sacramento Quarterly AIDS Report. (2008). County of Sacramento, Department of Health and Human Services, Division of Public Health, 1(1), 4-4. Retrieved from http://www.dhhs.saccounty.net/PUB/Documents/Disease-Control- Epidemiology/PUB_AIDSSacCtryQ12006_3_18_08.pdf DeNavas-Walt, C., & Proctor, B. D. (2014). Income and Poverty in the United States: 2013 (P60-249). Retrieved from United States Census Bureau website: http://www.census.gov/content/dam/Census/library/publications/2014/demo/p60-249.pdf Department of Health and Human Services (2015a). HIV/STD Testing sites. Retrieved from http://www.dhhs.saccounty.net/PUB/Pages/HIV-STD-Prevention-Program/GD-HIV-T esting-Sites.aspx Department of Health and Human Services (2015b). Non-prescription Sale of Syringes. Retrieved from. http://www.dhhs.saccounty.net/PUB/Pages/Non-Prescription -Sale-of-Syringes/Non-Prescription-Sale-of-Syringes.aspx Environmental Health. (2015, April 20). Retrieved April 18, 2015, from http://www.healthypeople.gov/2020/topics-objectives/topic/environmental-health Gamboa, S. (2012). Retrieved from http://www.huffingtonpost.com/2012/09/19/black-male-hs- graduation-_n_1896490.html Health and Human Services (HIV/STD Prevention Program). (2015, January 1). Retrieved March 6, 2015, from http://www.dhhs.saccounty.net/PUB/Pages/HIV-STD- Prevention-Program/SP-HIV-STD-Prevention-Program.aspx
  • 39. Barriers to Human Immunodeficiency Virus Prevention and Care 39 Herek, G., & Capitanio, J. (1999). AIDS Stigma and Sexual Prejudice. American Behavioral Scientist, 42(1126-1143), 2-2. HIV & AIDS Among African Americans | AVERT. (n.d.). Retrieved from http://www.avert.org/hiv-aids-among-african-americans.htm HIV Health Services Planning Council. (2015, January 1). Retrieved March 6, 2015, from http://www.sacramento-tga.com/ Jones, R. (2014, December 15). Gay Community in Sacramento Pushing for Lavender Heights to Become Official District (CBS Sacramento). Retrieved March 6, 2015, from http://sacramento.cbslocal.com/2014/12/15/gay-community-in-sacramento- pushing-for-midtowns-lavender-heights-to-become-official-district/ Malebranche, D. (2011, April 1). The truth about the “Down Low”. Retrieved from http://www.apa.org/pi/aids/resources/exchange/2011/04/down-low.aspx McKiernan, D., Bois, S., Alvy, L., & Jones, K. (2013). Health care access and health behaviors among men who have sex with men: The Cost of Health Disparities. Health Education & Behavior, 40(1), 32-41. Moyer, C. (2011, September 5). LGBT patients: Reluctant and underserved. Retrieved April 17, 2015, from http://www.amednews.com/article/20110905/profession/309059942/4/ National Coalition for LGBT Health. (2010). Community Based Prevention and the LGBT Community. Retrieved from http://lgbthealth.webolutionary.com/sites/default/ files/CTG%20FINAL.pdf National Coalition to Support Sexuality Education-Default Home Page. (n.d.). Retrieved March 6, 2015, from http://www.ncsse.com/index.cfm?fuseactuion=Page. ViewPage&Pageid=1013
  • 40. Barriers to Human Immunodeficiency Virus Prevention and Care 40 National HIV Testing Day. (2009, June 27). County of Sacramento, Department of Health and Human Services, Division of Public Health Retrieved from http://www.pio.saccounty.net/Press Releases/sac_019446.pdf Overstreet, N. M., Earnshaw, V. A., Kalichman, S. C., & Quinn, D. M. (2013). Internalized stigma and HIV status disclosure among HIV-positive black men who have sex with men. AIDS Care, 25(4), 466–471. doi:10.1080/09540121.2012.720362 Poverty and Crime: Breaking a Vicious Cycle of Discrimination. (2013, April 1). Retrieved April 20, 2015, from http://www.poverties.org/poverty-and-crime.html Pre-Exposure Prophylaxis (PrEP). (2014, September 30). Retrieved March 18, 2015, from http://www.cdc.gov/hiv/prevention/research/prep/ Pulai, A. (2003). The men’s soul food project feeds the needs of SGL men of African descent. Outward Magazine, 16. Retrieved from www.outwardmagazine.com Sacramento County Main Jail (1999). Final Report Internet Version. Retrieved from http://www.sacgrandjury.org/reports/98-99/gjury98-99-14.asp Sacramento Pride. (n.d.). About Sacramento Pride. Retrieved from https://www.sacramentopride.org/about.shtml Sex and HIV Education. (2015, March 1). Retrieved March 7, 2015, from http://www.guttmacher.org/statecenter/spibs/spib_SE.pdf Sood, N., Juday, T., Vanderpuye-Orgle, J., Rosenblatt, L., Romley, J., et al. (2014). HIV Care providers emphasize the importance of the Ryan White program for access to and quality of care. Health Affairs, 33(3), 394-400.
  • 41. Barriers to Human Immunodeficiency Virus Prevention and Care 41 Statistics-San Francisco AIDS Foundation. (n.d.). Retrieved from http://sfaf.org/hiv-info/ statistics/ The Affordable Care Act and HIV/AIDS. (2014). Retrieved from https://aids.gov/federal-resources/policies/health-care-reform/ Understanding Disparities in the HIV Epidemic. (n.d.). Retrieved February 12, 2015, from http://www.advocatesforyouth.org/publications/publications-a-z/524-understanding- disparities-in-the-hiv-epidemic- Wyatt, G. E. (2009). Enhancing Cultural and Contextual Intervention Strategies to Reduce HIV/AIDS Among African Americans. American Journal of Public Health, 99(11), 1941–1945. doi:10.2105/AJPH.2008.152181
  • 42. Barriers to Human Immunodeficiency Virus Prevention and Care 42 Appendices Marketing Product In the Knows’ PrEP for Love Program primarily focuses on the delivery of safe sex education, distribution of the medication Truvada and outreach to educate the at risk population and inform them of services available to help them avoid HIV infection. Promotion In the Know will utilize Facebook, Instagram, and Twitter to advertise the program to local residents. The popularity of social media, as well as its convenience as a tool that may be accessed anytime, make it an ideal approach for promotion of the program. Our health educators will also make appearances at all of the major Sacramento LGBT Community Center events, namely the Sacramento Pride Parade, Pride awards and Red dress party. In the Know will have a booth at the Sacramento LGBT Community Center’s healthcare event “Take Pride in Your Health Fair,” along with other organizations to publicize the PrEP for Love Program by passing out informational brochures detailing the program. This specific event offers free HIV testing and health screenings, which are benefits in line with what the PrEP for Love Program will provide as well. Our four health educators will also coordinate with local high schools to speak about the PrEP for Love program and its benefits to encourage of age participants to enroll and inform underage students about resources they may utilize in the future. Place The provision of an accommodating and tranquil environment for our participants each time they attend a monthly session will be provided by the Sacramento LGBT Community Center in downtown Sacramento at no cost to the program. Additionally, one of our major
  • 43. Barriers to Human Immunodeficiency Virus Prevention and Care 43 program partners, the Cares Community Health Clinic, is conveniently located just 7 minutes away from the Sacramento LGBT Community Center. Our disqualified participants will be referred to the CARES Clinic for health related services following a positive HIV test result. Price Our participants will be expected to attend all 1 ½ hour safe sex education classes and adhere to taking Truvada daily if the participant has opted to do so. Aside from maintain prompt attendance, we also encourage participants to share their personal experiences related sex and HIV or AIDS during our class sessions, however this is not mandatory due to the sensitivity of our program.
  • 44. Barriers to Human Immunodeficiency Virus Prevention and Care 44 Line Item Budget Proposal Expenses Total Project Budget Request to the California Endowment 1st Year 2nd Year 3rd Year (2 months) Total 1st Year 2nd Year 3rd Year (2 months) Total Personnel Program Manager (0.25 FTE) $30,500 $30,500 $5,083 $66,083 $24,400 $24,400 $4,066 $52,866 Health Educator (4 @ 0.50) $112,000 ($28,000 each) $112,000 $37,332 ($9,333 each) $261,332 $89,600 $89,600 $29,864 $209,064 Admin Assistant (0.10 FTE) $4,000 $4,000 $666 $8,666 $3,200 $3,200 $532 $6,832 Benefits/ Taxes 25% $36,625 $36,625 $40,162 $113,412 $35,400 $35,400 $8,615 $79,415 Total Personnel $183,125 $183,125 $83,243 $449,493 $152,600 $152,600 $43,077 $348,177 Non-Personnel Office Supplies $1,783 $1,783 $297 $3,863 $1,426 $1,426 $237 $3,089 Travel $1,153 $1,153 $192 $2,498 $922 $922 $153 $1,997 Postage $230 $230 $38 $498 $184 $184 $30 $398 Meeting Costs (in kind) $0 $0 $0 $0 $0 $0 $0 $0 Equipment (in kind) $0 $0 $0 $0 $0 $0 $0 $0 Advertising (in kind) $0 $0 $0 $0 $0 $0 $0 $0 Total non- personnel $3,166 $3,166 $527 $6,859 $2,532 $2,532 $420 $5,484 Grand Total $186,291 $186,291 $83,770 $456,352 $155,132 $155,132 $43,497 $353,661
  • 45. Barriers to Human Immunodeficiency Virus Prevention and Care 45 Budget Narrative Program Manager Direct program operations, advertising, monitor the budget, approve expenditures, structure the PrEP for Love monthly Truvada refill days and alternative pick up days for emergency’s and no shows and coordinate with partner organizations. Additionally, the program manager will organize the safe sex education classes, assist health educators prepare pre-tests and post-tests, monthly questionnaires and educational materials for the monthly safe sex education class. Health Educators Will lead and deliver safe sex education classes, develop and present PrEP for Love program information at our community outreach events and recruit program participants from local Sacramento County High Schools and Sacramento LGBT Community Center Events. Administrative Assistant Create and maintain filing of participant pre/post tests and monthly questionnaires, as well as tabulate participant attendance for each monthly pickup and support other staff. Volunteers Volunteers from the Sacramento LGBT Community Center will be responsible for the set up and breakdown of the PrEP for Love safe sex education classes, refill station for participants to pick up their monthly supply of Truvada and the distribution of condoms and lube during the classes. Volunteers will create the flyers and posters used to promote safe sex and the PrEP for Love program at local Sacramento County high schools and Sacramento LGBT Community Center events.
  • 46. Barriers to Human Immunodeficiency Virus Prevention and Care 46 Non-personnel Office Supplies Includes a printer, printer toner, paper, two staplers and staples, pens, pencils, highlighters and filing folders. A Xerox WorkCentre 6505 dn color multifunction printer will cost $574.95, and will be used for all organizational printing needs such as fliers, pre and post surveys, questionnaires, contracts, financial statements, etc. Printer toner and 5,000 sheets of paper will cost roughly $2895.74 and $91.98 respectively, for the complete duration of the program. Pens, pencils, highlighters, staplers and staples and folders will be purchased for $302.21, for the entire program. Meeting costs The Sacramento LGBT Community Center has agreed to host the PrEP for Love Program for its duration at no cost. This includes seating, tables and volunteers from the community center to set up and break down safe sex education classes and the Truvada check in and pick up station. Equipment The Cares Community Health Clinic will contribute 75 monthly Orasure HIV tests to the PrEP for Love Program as well as any personal protective equipment needed for administering the test, such as gloves. Gilead Pharmaceuticals will donate the monthly allotment of 75 bottles of Truvada for 12 months, totaling 900 bottles of Truvada during the program. Travel In the Know will provide daily bus pass vouchers for in-need individuals, up to $2,500. Postage An allotment of $500 will be available for postage.
  • 47. Barriers to Human Immunodeficiency Virus Prevention and Care 47 Advertising In the Know will market the PrEP for Love Program for free at local Sacramento County High Schools and Sacramento LGBT Community Center events. Fliers and informational brochures will be printed by In the Know and mailed to potential participants and/or participants and passed out during LGBT events; the cost for this is covered under postage and office supplies.