Topic Areas

Stigma

Stigma has been identified as a barrier to achieving the District’s 90-90-90-50 goals through DC Appleseed’s interviews of stakeholders over many years and through community engagement sessions that DC Health held in 2019 and 2020. There are many good ideas about how to combat stigma, some of which DC Health has already adopted. However, it has been challenging to develop metrics that might evaluate the success of those interventions. DC Appleseed is reviewing the literature to evaluate approaches to measuring stigma. DC Health could use the metrics DC Appleseed develops to track how stigma changes as a result of efforts to combat it. DC Appleseed will recommend whether and how the District should move forward in its own attempts based on this review.

Quality Metrics

Managed care organizations (MCOs) have the opportunity to do much more in support of ending the epidemic. This includes adopting and implementing HIV-related performance measures and thresholds, such as measures of the percentage of HIV-positive patients who are engaged in care, monitoring their viral load, and being screened for other STDs. There are also opportunities for the DC government to require or incentivize certain efforts by MCOs, such as adding performance measures to future contracts with MCOs to enhance treatment adherence, viral load suppression, and funding for support services. DC Appleseed will review and update its 2019 recommendations in this area.

Workforce

Through its own interviews and review of data from DC Health’s community engagement sessions, DC Appleseed is aware of the desire by many communities for more peer education and outreach such as through community health workers and peer navigators. Current efforts are somewhat disparate — government-funded versus privately funded, full-time versus volunteer. Various programs also measure success differently. DC Appleseed is interviewing community health and workforce development experts to clarify what types of roles are likely to be most successful in reaching which populations. DC Appleseed will also share best practices for how to measure success, so that peer education and outreach can be better monitored as part of the District’s plan to end the HIV epidemic.

Youth

The District’s youth population has benefited disproportionately less than other groups from efforts to end the HIV epidemic. DC Appleseed is investigating the extent of this disproportionality by reviewing data for each of the 90-90-90-50 categories and reported progress on youth-oriented tasks from the 2015 report. With that as a baseline, DC Appleseed will also evaluate how well past and current interventions have been implemented. This will include reviewing progress by the school system in meeting its objectives, reviewing the report from DC’s Office of the Inspector General’s on compliance with the Healthy Schools Act, and interviewing stakeholders and decision-makers. To make recommendations for how to better serve youths, DC Appleseed will conduct stakeholder interviews and review best practices for reaching youths through technological innovations in addition to considering key takeaways from their review of progress to date.

First Challenge: Social Threats

First, there are fundamental social threats: structural racism, stigma, and inequity. The negative impact of racism on health is widely recognized, and ongoing systemic, structural change is needed to improve health outcomes in historically marginalized communities. Improving health and well-being in these communities is no small task — meaningful change requires respect and cultural humility while addressing ways to undo the systems that hold damaging policies in place. As part of this plan and for all future actions, DC Health acknowledges and will address the impact of structural racism on sexual health and HIV outcomes.We will begin by developing a framework for promoting social justice in our work, centering the voices and lives of Black and Latino people and creating our principles and dedicating resources to erode racism and inequity. Internally, DC Health will intentionally look at race and racism, working mindfully and fully taking into account the diversity of the populations it serves, the diversity of its workforce, and the larger context in which DC Health delivers programs and develops policies.

DC Health will:

  • Create spaces to discuss racism at internalized, interpersonal, institutional, and structural levels and how these different manifestations of racism affect its work.
  • Agree on a framework and strategies to address racism within DC Health, as well as in policies and programs.
  • Define internal guiding principles for addressing racism.
  • Agree on metrics to measure progress on becoming an anti-racist organization.

Acknowledging structural racism and addressing it are fundamental to ensuring equity. It is equally important to assure equitable access to resources and opportunity to all people, regardless of racial, ethnic, gender, and sexual identities. DC Health has developed programs on drug user health, sexual pleasure, and social and emotional well-being, and initiatives that address issues such as employment, fellowship, and housing. It has also aimed to not assign risk to people based on their identities, instead defining risk in terms of behavior (for example, not wearing condoms, not knowing the status of a partner) to lessen the stigma people might feel. All recent programs and efforts have aimed for diversity, equity, and inclusion of a number of populations often left at the margins, as well as to decrease the stigma placed on some of these populations.

Additional ongoing initiatives that help increase equity and reduce stigma are:

  • Undetectable Equals Untransmittable (U=U)
    DC Health was the second health department in the nation to endorse the Undetectable Equals Untransmittable, or U=U, consensus statement as a significant message to emphasize treatment adherence, reduce stigma for people living with HIV, and prevent new HIV transmissions. DC Health expects to integrate U=U into clinical and support services by pairing U=U messaging with other sexual health education campaigns, translating messaging into Spanish, and including it as a main strategy in planning efforts.
  • Health Impact Specialists
    In 2015, DC Health received a four-year demonstration grant from the Centers for Disease Control and Prevention (CDC) focused on creating a system of care for men who ​have sex with men and for transgender persons of color​. As a part of this program, DC Health hired Health Impact Specialists from communities affected by HIV to provide health and wellness information and resources to peers, thus providing an opportunity for economic growth while putting health resources into the same communities. It is a model for activating social justice and empowerment.
  • Rapid Peer Responders
    Rapid Peer Responders address the health of people who use drugs through a harm reduction approach. Similar to the Health Impact Specialists, these responders are individuals from the community they serve, and who have employment challenges such as recent incarceration experience or limited work experience in the formal economy​.
  • Status-Neutral/Regional Early Intervention Services
    DC Health has developed a status-neutral approach, responding to individuals’ sexual health needs wherever they are on the HIV prevention and treatment continuum. This status-neutral approach is delivered using the “Hi-V model” (pronounced “high-five”),  which consists of five pillars of client-centered services that promote equity and whole person health. The five pillars are find ’em, teach ’em, test ’em, link ’em, keep ’em, and the model is designed to eliminate barriers to prevention and treatment services. These services are delivered to focus populations — that is, those that are at very high risk of HIV infection, have demonstrated high HIV prevalence, have inconsistent engagement in care and treatment, or are at increased risk of falling out of care and treatment.

Second Challenge: Local Realities

Second, there are local challenges to the District’s reaching its goal, obstacles that reflect geography and life priorities as expressed by residents during community engagement sessions, a series of small gatherings held with a diversity of groups throughout 2020.

One challenge to ending the HIV epidemic in the District is that it’s a small jurisdiction within a large and complex metropolitan area that includes parts of three other states. People live, work, play, and access health services irrespective of jurisdictional lines. The metropolitan area covers counties in Maryland, Virginia, and West Virginia, and the District. Two jurisdictions that also received funding through CDC’s Ending the HIV Epidemic initiative — Montgomery County and Prince George’s County — directly border the District. Baltimore City, another funded jurisdiction, is 30 miles from Washington.

Another challenge is how HIV factors in the lives of focus populations. DC Health initiated its community engagement sessions with a simple yet multilayered question: “What’s going on in the lives of (your population)?” Subsequent questions included asking about resiliency and impacts on the population, the role of sexual health, and resources that would support overall health. Among a diversity of community members, HIV health was not among the top concerns.

The following sections present findings from a needs assessment, emerging themes from community engagement sessions, and additional strategies and activities DC is including in its updated Ending the Epidemic plan.

Findings From a Needs Assessment

The Washington, DC Regional Planning Commission on Health and HIV (COHAH), which serves as the Ryan White Planning Council and HIV Prevention Planning Group, completed a needs assessment in 2017 as a part of COHAH activities to regularly evaluate Ryan White services and the needs of community. Data from this needs assessment show that overall, people living with HIV were:

  • Engaged in care.
  • Received outpatient ambulatory health services on a timely basis.
  • Used antiretroviral medication at a high rate and as prescribed.

Respondents in focus groups and interviews identified mental health services, psychosocial support, and assistance with housing services in the eligible metropolitan area as important needs. When it came to linking with HIV care, the most consistently reported barriers across communities were psychosocial and emotional factors. Barriers to using and adhering to HIV care and treatment included the cost of housing, the availability of housing, and discrimination in housing, particularly in DC and Maryland.

To address some of these barriers — especially as they affect marginalized populations — DC is:

  • Working toward formal certification for community health workers and expanding the community health worker and peer navigator models. Community health workers have access to and the trust of communities, making them an integral part of linkage and retention to care efforts, particularly for those who are marginalized, have stopped receiving care, or are newly diagnosed.
  • Addressing housing by updating its navigator program to include navigation and referral services, as well as transitional, short-term, and emergency housing assistance to enable people living with HIV to gain or maintain outpatient and ambulatory health services and treatment.
  • Developing a wellness support service category with its Ryan White funds to support holistic well-being, providing additional services that complement mental health and psychosocial support services. The Regional Early Intervention Services initiative is a status-neutral approach toward prevention and care services and is described below in more detail.

COVID-19 interrupted DC’s 2020 needs assessment, so the next comprehensive needs assessment will be conducted in 2021. There will be an emphasis on reaching people who are out of care or recently re-engaged in care. The needs assessment will also include people who are HIV negative to better understand HIV prevention needs.

Emerging Themes From Community Engagement

In October 2019, DC Health increased its efforts to engage communities, but paused those activities in March 2020 to launch COVID-19 prevention measures. In May 2020, DC Health resumed its engagement activities, using virtual platforms.

Through these efforts, as of late 2020, DC Health has heard from approximately 740 community members from a diversity of communities, many who are not traditionally part of engagement efforts or meetings. While many unique experiences were shared during population-specific sessions, several themes arose across communities:

Cross-Community Themes Components
Stress
  • Life and work balance
  • Generational trauma
  • "Super Woman Syndrome"
  • Violence
Connection
  • Finding partners
  • Communal spaces
  • Peer/support groups
Culture
  • Stigma, shame, fear
  • Misinformation
  • Perception of risk
  • Family/gender roles
Identity
  • Gay
  • Transgender
  • Gender
  • Nationality
Structural Issues
  • Healthcare access
  • Mental Health
  • Language
Social Determinants
  • Socioeconomic status
  • Education
  • Returning citizen status

Snapshot of Activities by Pillars

DC determined the strategies for its updated plan using a health-equity and trauma-informed framework. DC’s strategies are: testing, U=U, pre-exposure prophylaxis and post-exposure prophylaxis (PrEP and PEP), rapid antiretroviral therapy (Rapid ART), molecular surveillance, Data to Care, harm reduction, and wellness services. These strategies align with the four federal pillars — Diagnose, Treat, Prevent, and Respond — and an additional, DC-specific pillar, Engage.

Resources in the form of partnerships, funding, and new approaches will support the planning and development of programs to carry out these strategies. DC Health will ensure that programs are accessible and responsive to DC’s diverse communities and their unique intersectional needs.

DC Health continues to leverage its working partnerships across jurisdictions, including community providers and consumer and stakeholder groups and entities in government, academia, and education. Funding through the Health Resources and Services Administration (HRSA) 20-078 and the CDC PS20-2010 enables DC Health to expand access to programs, supporting the availability of innovative and effective medical, support, and prevention services, to people living with HIV and people who are HIV negative. Under HRSA-20-078, the funding will also engage people who previously were not eligible to receive Ryan White services. In addition, DC Health received a supplemental Ending the Epidemic award through the National Institutes of Health-funded District of Columbia Center for AIDS Research (DC CFAR) for planning new approaches on PrEP, molecular surveillance, and Rapid ART.

DC Health has adopted a status-neutral approach through the Regional Early Intervention Services model to create innovative and culturally appropriate services, either within specific stages or along the full continuum of HIV prevention, testing, care, and treatment. The goal is to improve access to and use of high-quality, client-centered services for individuals living in the DC eligible metropolitan area most affected by the HIV epidemic.

In addition, DC Health continues its commitment to address health inequities in communities. It will build on its work with the DMV (District of Columbia, Maryland, and Virginia) Collaborative, innovative and expanded Data to Care, and the intersection of HIV and opioid use, while recognizing the impact of COVID-19 within systems of power and privilege.

Diagnose

Treat

Prevent

Respond

Engage

Explore Key Strategies

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