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Ryan White Part A: Harm Reduction Services

Ryan White Part A: Harm Reduction Services. Integration of Care Committee HIV Planning Council of New York City Danny Stewart Safe Horizon Streetwork Program May 20, 2011. Streetwork Programs.

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Ryan White Part A: Harm Reduction Services

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  1. Ryan White Part A: Harm Reduction Services Integration of Care Committee HIV Planning Council of New York City Danny Stewart Safe Horizon Streetwork Program May 20, 2011

  2. Streetwork Programs Streetwork started in 1984 as a street-outreach program in Times Square for homeless and street-involved youth and young adults to age 24. Streetwork has grown to include: • Drop-In Centers • Uptown • LES • Residential (emergency shelter) • Harlem • Midtown • Outreach (late night, 5 boroughs)

  3. Mission Statement We are committed to reaching out to homeless and disenfranchised youth offering them respite from hunger, cold, loneliness and fear, and the opportunity to reclaim or maintain a sense of dignity and self-worth. Our goal is to extend ourselves to these young people through our presence on the streets, through the services we provide, and through the love we are willing to express. With every meal, medical appointment, referral, condom and group we offer, we communicate to our clients our concern for their lives and our belief in their potential. Our mission is to act as a catalyst for their self-empowerment.

  4. Streetwork Clients Risk Factors • Homelessness • Trauma & violence • Mental health issues • Survival sex work • Substance use

  5. Streetwork Client Data January 1—December 31, 2010 Total Drop-In Center Clients: 994 Average daily attendance: 77

  6. Demographics:

  7. Demographics March 1, 2010—February 28, 2011 31 clients enrolled in HRR—all HIV positive Retention rate (July 1, 2010—March 31, 2011): 50%

  8. Effective Approaches in Working with Youth Positive Youth Development—focuses on a strengths perspective to promote healthy, responsible, and compassionate choices • Building strengths or assets—protective factors (resiliency) that impact risks • Youth engagement, voice, involvement • Relationship building • Long term involvement

  9. Positive Youth Development • Assets Coming Together (ACT) for Youth Downstate Center for Excellence, ACT for Youth Upstate Center of Excellence. (2003). A Guide to Positive Youth Development. New York: Mount Sinai Adolescent Health Center. Website: www.actforyouth.net • Birkhead, G.S., Kreipe, R.E., Klein, S.J. (Supplement Eds.) Journal of Public Health Management and Practice. 2006, November (Supplement). Supplement focus: Improving public health through youth development. • Dotterweich, J. (2006) Positive Youth Development Resource Manual. Ithaca, NY: Cornell University, ACT for Youth. • Goggin, S., Powers, J., Spano, S. (2002). Profiles of Youth Engagement and Voice in New York State: Current Strategies. Based upon the work supported by the Cooperative State Research, Education, Extension Services, U.S.Department of Agriculture, and the Cooperative Extension Service, Cornell University, Children, Youth and Family At Risk Program.

  10. Effective Approaches in Working with Youth Client-Centered Practice—individuals have the capacity to change and grow through empathy and unconditional acceptance. The focus is on the client’s interests & concerns. • Honor and respect • Compassionate responses • Clients can make informed decisions • Non-judgmental approach

  11. Client-Centered Practice • Grieder D & Theis G  (2008). Wisconsin: leading the way to person-centered planning in community-based health   International Journal of Psychosocial Rehabilitation. 12(2), 111-114. • Finfgeld, D. L. (2004). Empowerment of individuals with enduring mental health problems: results from concept analyses and qualitative investigations. Advances in Nursing Science, 27(1), 44-52. • Markland, D., Ryan, R. M., Tobin, V. J., & Rollnick, S. (2005). Motivational interviewing and self determination theory. Journal of Social & Clinical Psychology, 24(6), 811-831. • Meichenbaum, D., & Turk, D.C. Facilitating Treatment Adherence. (1987). Kluwer Academic Publishers. • Wahl, Chris. Gregoire, J.P., Koon, T., et.al. (2004). Concordance, compliance and adherence in health care: closing gaps and improving outcomes. Healthcare Quarterly, 8(1) 2005: 65-70.

  12. Youth & HIV Testing • HIV positive results—youth tend to engage in some level of sexual risk behavior. Murphy, D., Moscicki, A., Vermund, S., Muenz, L. Psychological distress among HIV positive adolescents in the REACH study: effects of life stress, social support and coping. Journal of Adolescent Health. 27 (6), Dec. 2000, 391-398. Murphy, D., Durako, S., Moscicki, A., Vermund, S., Ma, Y., Schwarz, D., Muenz, L. No change in health risk behaviors over time among HIV infected adolescents in care: role of psychological distress. Journal of Adolescent Health. 29 (Suppl. 3), Sept. 2001, 57-63. Rotheram-Borus, M., Lee, M., Zhou, S., O’Hara, P., Birnbaum, J., Swendeman, D., Wright, W., Pennbridge, J., Wright, R. Variation in health risk behavior among youth living with HIV.AIDS Education and Prevention. 13 (1), Feb. 2001, 42-54.

  13. Effective Interventions Case Management—a formal and systematic multi-step process designed to assess the needs of a client to ensure access to needed services. It strives to ensure that clients with complex needs receive timely coordinated services. The case manager functions as an advocate for services for the client, with particular emphasis placed on the client’s self sufficiency in the community.

  14. Case Management • Gardner, LI, Metsch, LR, Anderson-Mahoney, P, Loughlin, AM, del Rio, C, Strathdee, S, Sansom, SL, Siegal, HA, Greenberg, AE, Holmberg, SD (2005). Antiretroviral Treatment and Access Study Group. Efficacy of a Brief Case Management Intervention to Link Recently Diagnosed HIV-Infected Persons to Care. AIDS. 19(4):423-31. • Katz, MH, Cunningham, WE, Mor V, Andersen, RM, Kellogg, T, Zierler, S, Crystal, SC, Stein, MD, Cylar, K, Bozzette, SA, Shapiro, MF. (2000). Prevalence and Predictors of Unmet Need for Supportive Services Among HIV-Infected Persons: Impact of Case Management. Medical Care. 38(1):58-69. • Katz, MH, Cunningham WE, Fleishman, JA, Andersen, RM, Kellogg, T, Bozzette, SA, Shapiro, MF. (2001). Effect of case management on unmet needs and utilization of medical care and medications among HIV-infected persons. Annals of Internal Medicine. 16;135(8 Pt 1):610-2. • Kushel, MB, Colfax, G, Ragland, K, et al. (2006). Case management is associated with improved antiretroviral adherence and CD4+ cell counts in homeless and marginally housed individuals with HIV infection. Clinical Infectious Diseases. 43(2):234-242.

  15. Effective Interventions Sexuality and Sex Education—process of acquiring information and forming attitudes and beliefs about sex, sexual orientation, relationships and intimacy. It is also about developing individual’s skills so that they make informed decisions, and feel confident and competent about acting on these decisions.

  16. Sexuality and Sex Education • Haglund, K. Recommendations for sexuality education for early adolescents. (2006). Journal of Obstetrics, Gynecology and Neonatal Nursing. 35(3):369-75. • Robinson, BB, Uhl, G, Miner, M, Bockting, WO, Scheltema, KE, Rosser, BR, Westover, B. (2002). Evaluation of a sexual health approach to prevent HIV among low income, urban, primarily African American women: results of a randomized controlled trial. AIDS Education and Prevention. 14(3 Suppl A):81-96. • Shapiro, K, Ray, S. (2007). Sexual health for people living with HIV. Reproductive Health Matters. 2007;15(29 Suppl.):67-92. • UNAIDS. (1997). Impact of HIV and Sexual Health Education on the Sexual Behavior of Young People: A Review Update. Report prepared by UNAIDS, The Joint United Nations Programme on HIV/AIDS for World AIDS Day.

  17. Homelessness, HIV & Youth • Homelessness/unstable housing is one of the most important barriers to use of ART • High viral load, recent OI, and HIV hospitalization are associated with homelessness/unstable housing • Lack of housing creates/maintains pervasive context of risk makes it hard to avoid risky situations or to use risk-reducing tools • Findings suggest that the condition of homelessness—and not simply traits of homeless individuals—influences risk behaviors and service utilization. • Aidala, Angela. (2008). Housing is HIV prevention and care. HIV Center for Clinical and Behavioral Studies. Presentation: April 10, 2008.

  18. Homelessness, HIV & Youth • Homeless youth need more than treatment for substance use. • “While the CRA program was successful, I think what we do in treatment is less important than the process. The content is not as important as having these teens come in and talk to a therapist and develop a new, positive experience with an adult. That is what they really need.” • Slesnick, N., Prestopnik, J. L., Meyers, R. J., & Glassman, M. (2007). Treatment outcome for street-living, homeless youth. Addictive Behaviors; 32:1237–1251.

  19. Homelessness, HIV & Youth • Among YMSM—homelessness, rather than knowledge, attitude, or intention, seemed to predict both drug and sexual risk. • Clatts, MC, Goldsamt, LA, Yi, H. (2005). Drug and sexual risk in four men who have sex with men populations: evidence for a sustained HIV epidemic in New York City. Journal of Urban Health; 82 (1, Supplement 1): i9-i17.

  20. Homelessness, HIV & Youth • Few YMSM who have become homeless have used drugs prior to their becoming homeless. • Involvement in the street economy, including sex work and drug use, are better understood as adaptations to homelessness, rather than causes of it. • structural interventions—systemic approaches to more effective means of reaching, engaging, and retaining homeless YMSM in shelter services and permanent housing programs—should be central considerations in formulating HIV and other public health interventions targeted to this population. • Clatts, MC, Goldsamt, L, Yi, H, Gwadz, MV (2005). Homelessness and drug abuse among young men who have sex with men in New York City: A preliminary epidemiological trajectory. Journal of Adolescence, 28(2): 201-214.

  21. Homelessness, HIV & Youth • Homeless youth need an ongoing safety net. • Youths’ need for a safety net are not short-term, but intended to provide assistance over an extended period of time (12-33 months) until youth become stably housed. • There is no model that anticipates that the youth will be able to protect themselves from HIV without a holistic approach that supports the youths’ development and capacity building. • Arnold, EM, Rotheram-Borus, MJ. (2009). Comparisons of prevention programs for homeless youth. Prevention Science;10(1):76-86.

  22. Conclusions • One-size fits all interventions are not effective—especially with youth. • For maximum effectiveness, evidence-based programming must include a long-term investment with an emphasis on a counseling relationship and creating stability with homeless HIV + youth. • Behavior change occurs in the context of a relationship—where youth are supported and unconditional love and acceptance are conveyed. • Public health strategies are most effective when they involve a strong collaboration with the community

  23. Contact Information Danny Stewart Director of Operations Streetwork Safe Horizon 646-214-3806 dstewart@safehorizon.org

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