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.
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.
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.
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, 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:
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:
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.
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:
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:
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.
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:
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.
DC Health has maintained its contracting relationship with 19 clinical and nonclinical community-based organizations to provide HIV testing and links to services. These partnerships have made it possible to continue providing residents either lab-based or point-of-care rapid HIV screenings. While COVID-19 has interrupted services, an unexpected success has been the creation of new protocols to safely continue to offer HIV screening to clients in this environment. Programs have developed various models that are tailored to their structures. DC Health has facilitated meetings between HIV screening providers and community COVID-19 testing sites to learn specific approaches and workflows.
DC Health responded to pandemic-related closures and reductions in health care services, particularly HIV testing, by designing and implementing an at-home testing program. Launched at the end of June 2020, GetCheckedDC.org allows residents to request, for free, the OraQuick at-home HIV test kits. DC Health sends a questionnaire 14 days afterward to ask about the person’s results and experience with the program.
Data indicate that this program is succeeding in terms of overall number of test kits distributed and the satisfaction of residents who have received a kit. In its first five months, it reached more than 900 District residents. Over half of participants indicated using the program due to “effects of the COVID pandemic.” Almost 40% of participants last received an HIV test “more than 12 months ago” and nearly 7% indicated that they had “never been tested for HIV.” DC Health will increase the program’s outreach, particularly among focus populations, into 2021 by partnering with community-based providers to distribute test kits.
In September 2020, DC Health added two new components to GetCheckedDC.org: at-home test kits for sexually transmitted diseases (STDs) and walk-in testing for HIV, STD, and hepatitis.
DC Health’s Annual Epidemiology & Surveillance Report for 2020 states that 12,408 current residents of the District of Columbia — or 1.8% of the population — are living with HIV. Among people newly diagnosed, 62% were linked to medical care within seven days of diagnosis and 81% within 30 days. Viral suppression among people known to be living with HIV in DC remained at 69% overall and 87% among people with an indication of engagement in care. DC Health supported community-based and clinical providers that offered HIV screening and linkage to care. Community providers continued their linkage to care approach of confirming a linkage to care appointment within 72 hours of diagnosis (under the DC Red Carpet Entry protocol), in part through the following programs.
LinkU is an online resource and referral platform launched by DC Health for internal and external partners and community members. The website linkudmv.org contains the full range of community providers in the DC metropolitan area. One feature of LinkU is the ability to make appointments directly with providers, which also enables providers to track and evaluate referral and outcomes related to those contacts. Additional features, such as specialty tabs for specific subpopulations (e.g., HIV-positive mothers) were added. Search tabs were adjusted based on feedback from providers and community members.
DC Health’s Youth Reach is a Minority AIDS Initiative-funded program focused on serving youth and young adults of color ages 13 to 30 in the following subpopulations: Black women, Black or Latino men who have sex with men, Black heterosexual men, and Black or Latino transgender women. Youth and young adults are shown to have low rates of viral suppression. To address these health outcomes, services provided are culturally and linguistically appropriate, and encompass a wide referral and linkage network that is readily able to address the varying needs of this population. Entities funded under the Youth Reach program provide a cadre of services designed to facilitate a seamless transition from prevention and testing programs into care and from pediatric to adult care through a coordinated cluster of services.
The DC Adhere mobile application was officially rolled out to pharmacies, providers, and clients associated with the AIDS Drug Assistance Program (ADAP) administered by DC Health. This app is designed to track prescription pickup (at the point of sale); send alerts and reminders to clients concerning prescriptions and ADAP enrollment; track use of daily prescribed medications (voluntary); and generate client and population level reports. Trainings were conducted for pharmacy and physician providers as part of the rollout process, providing an overview of utilization requirements and end-user procedures.
New initiatives: As part of HRSA 20-078 funding, DC will be able to expand services to more people living with HIV, as well as provide new innovative initiatives. DC will implement three program initiatives: the integration of clinical care coordinators into private provider care systems; integrated health and wellness; and a community disease intervention specialist project with enhanced data to action. With more than half of DC residents with HIV receiving care by private providers, the proposal will address gaps in support to ensure engagement in care and treatment adherence. The integrated health approach will address the barriers to engaging in care by reducing chronic conditions and stress factors that reduce treatment effectiveness. A new approach to build trust with newly diagnosed individuals will result in timely engagement of the partners of those with HIV, and ultimately, reduced infections.
DC Health continues to work to increase capacity for comprehensive preventive health services including support for providers to offer PrEP services, outreach and wellness activities, linkages to STD and hepatitis C screening, condom distribution, and behavioral interventions.
PrEP: Based on data reported by DC Health-funded PrEP providers, 69% of HIV-negative clients received a PrEP assessment and 14% of those individuals received a clinical visit for PrEP. Of those assessed, 93% received a prescription for PrEP medication. DC Health has been participating in a supplemental DC CFAR project on citywide scale-up of PrEP. Through the project, DC Health will examine strategies to increase the acceptability and sustained use of PrEP among these populations: African American gay men, Latinos, adolescents and young adults, African American women, and people who use drugs.
PEP: DC Health will continue to develop its post-exposure prophylaxis (PEP) initiative to increase accessibility while developing new messages and engagement strategies to increase condom distribution and promotion. DC Health maintained its public sector condom distribution program, which comprises more than 300 community and business distribution sites and a direct mail component to DC residents. In 2019, DC Health distributed more than 4 million condoms.
Harm reduction and opioid-related: DC Health has expanded its harm reduction and opioid-related services. This included the expansion of hepatitis C screening and treatment, medication assisted therapy (MAT) services, syringe exchange, harm reduction activities, and wraparound services for people living with HIV. DC Health currently supports four syringe service providers serving approximately 10,000 people who inject drugs. In the 2019 Annual Surveillance Report, only two new HIV cases were attributable to injection drug use, representing 0.7% of all new diagnoses, an 80% decrease from 10 cases in 2018 and a 99% decrease from 150 cases in 2007.
Harm reduction serves a critical role in a continuum of services for people who use drugs. Socioeconomic conditions, trauma, social isolation, discrimination, stigma, and other inequities are factors in the lives of persons who use drugs, and DC Health works with providers to incorporate these factors in harm reduction approaches. DC Health has integrated overdose prevention into syringe exchange programs and increased naloxone distribution. DC Health has also implemented a Rapid Peer Responder program to link individuals who have active opiate use disorder and are at high risk for overdose to buprenorphine-based MAT, including screening and potential linkage to care. These peer referral specialists serve as rapid responders to those recently experiencing overdose and are trained in an intervention model that features screening, brief intervention, and referral to treatment. A web-based appointment system links individuals in need of rapid engagement to treatment with clinicians trained to provide buprenorphine. DC Health continues to work with syringe service providers to increase capacity to provide comprehensive preventive health services and increase linkage to care of HIV and hepatitis C.
Many prevention activities continue to be delivered through virtual and telehealth modalities as of early 2021. These interventions are conducted at the individual, group, and community level. Harm reduction services, such as syringe service programs and condom distribution, have continued on a limited basis. Community partners providing in-person services have employed best practices in minimizing COVID-19 exposure.
Each month, genetic sequences are analyzed through use of tools such as Secure HIV-TRACE to pinpoint clusters — groups of people living with HIV, diagnosed or undiagnosed, who are connected by HIV transmission — for investigation. Cluster members are then prioritized based on last known viral load and manually searched in the STD surveillance and partner services database (DC Public Health Information System). Named partners of cluster members identified after HIV diagnosis are incorporated into the cluster profiles. Case information gathered from HIV and STD surveillance and partner services programs are outlined in a dataset for review. Each case is then assigned a disposition for follow-up. Cluster investigations begin with contacting each cluster member’s last known provider or, if unknown, the department of health where each person lives. Based on the information found through that contact, the cluster member may then be recommended for re-engagement or linkage to care activities.
DC Health has maintained as much of the core functions of cluster investigations as possible during the pandemic, and all field services have been conducted by telephone. Conducting re-engagement and linkage activities has been a challenge. Most providers were forced to alter their operations, either moving to telemedicine or closing entirely. As a result, between March and May 2020, DC Health was not able to contact patients directly or re-engage. As DC began its phased reopening, infectious disease providers increased their availability and acceptance of re-engagement appointments and the activities were able to resume. DC Health has resumed re-engagement and linkage activities by telephone, allowing it to confirm appointments and attendance.
DC Health has added a fifth pillar to its initiative to end the HIV epidemic: Engage. The purpose of this pillar is to pilot and integrate strategies to address the structural and individual challenges to uptake of health activities — challenges that include racism, stigma, and inequities in health and wellness. DC Health has laid the groundwork in addressing some of these conditions.
To reduce stigma, DC Health has adopted a visibility approach. It has centered sexual well-being in its two social marketing programs — one for general and focus populations, and a second for youth and young adults. DC Health maintains the Sexual Being campaign for its general population program. The program featured action-oriented messages on HIV testing, PrEP, HIV treatment, and U=U. Bienestar DC, which translates to well-being and is a new campaign for the Latino community, has been launched to provide information on general sexual health as well as STD- and HIV-related information. DC Health’s LatinX Working Group, Mi Gente, conducted community engagement on messages that would be most effective for Latinos. DC Health continues its program focused on youths and young adults (ages 12 to 24) called Sex is... and also launched a Spanish-language version, Sexo es... with a website and promotional materials.
DC Health redesigned its funding process for community-based organizations to make it more equitable. It eliminated a requirement for a lengthy written narrative application, which disadvantaged smaller, population-focused organizations that lack skilled grant-writing staff or resources. It added a decisional site visit to enable smaller organizations to demonstrate their cultural humility and competency, staff expertise, and the infrastructure to administer the funding. These changes resulted in first-time funding for a transgender-led organization, a small Latino community-based provider, and non-HIV-focused organizations that specialize in wellness and behavioral health. As of December 2020, DC Health is conducting a Lean Six Sigma examination of its funding processes to further streamline processes to promote equity.
DC Health launched an internal initiative to examine its opportunity as an HIV-focused administration to contribute to addressing structural racism. This process recognizes that DC Health must approach this important condition with humility. Its Ending the Epidemic plan must recognize structural racism as a challenge to achieving the goal of reduced new HIV diagnoses and optimal well-being for people living with HIV.