A tremendous need exists to engage hard-to-reach populations in HIV/AIDS care. That’s because numerous factors prevent people living with HIV/AIDS (PLWHA)—especially disadvantaged and disproportionately affected populations—from engaging in care or remaining in care. This Webcast introduces providers to several successful strategies for reaching the most vulnerable populations: Howell Strauss, DMD, AIDS Care Group, discusses traditional street outreach, as well as his involvement with both the SPNS Oral Health Initiative and the SPNS Jail Initiative. Lisa Hightow-Weidman, MD, MPH, Department of Infectious Diseases University of North Carolina at Chapel Hill, shares best practices in social marketing outreach in the context of her work as a SPNS Young Men who Have Sex with Men of Color Initiative grantee.

1. Engaging Hard-to-Reach Populations: Outreach
Webinar Series
April 18, 2013

2. Agenda

Brief introduction to the new SPNS IHIP project (Sarah Cook-Raymond, Impact
Marketing + Communications)

Presentations from SPNS grantees on using data to improve outreach
 Howell I. Strauss, DMD; AIDS Care Group
 Lisa Hightow-Weidman, MD, MPH; University of North Carolina at Chapel Hill

Q &A

Very brief post-Webinar questionnaire

3. Introducing IHIP…
SPNS recently launched the “Integrating HIV Innovative
Practices” (IHIP) project.
IHIP takes innovative findings from SPNS initiatives and assists
health care providers in replicating proven models of care.
The result? Improved care delivery and healthier patients.

4. 
Lessons learned from across SPNS initiatives have been
distilled into engaging hard-to-reach educational materials.

Other IHIP products exist and more are rolling out.

To access IHIP materials, visit www.careacttarget.org/ihip.

5. “Engaging Hard to Reach Populations”
Howell I. Strauss, DMD
AIDS Care Group
Chester, PA

6. From the National HIV/AIDS
Strategy (2010):
The United States will become a place
where new HIV infections are rare and
when they do occur, every person,
regardless of age, gender, race/ethnicity,
sexual orientation, gender identity or
socio-economic circumstance, will have
unfettered access to high quality, lifeextending care, free from stigma and
discrimination.

7. Dr. Jonathan Mann in addressing the HIV
epidemic in developing nations asked, “Do
we need more doctors, nurses, and
clinics? Or, do we need to address other
basic societal issues, such as human
rights and issues surrounding poverty.”
(Johns Hopkins Clinical Care Conference, March 1997)

8. Major DECLINE in the Implementation
Cascade

9. “America works best when
the poor achieve their
dreams.”
Former President Bill Clinton,
Democratic National Convention
July 2004

10. Since 1997, over the next 15 years:
The gaps between rich and poor,
privileged and needy, and insiders and
outsiders have grown into chasms.

11. One in five children in our country is living
in poverty.
There are fewer jobs and there are more
abandoned homes.
There is more food insecurity.
There are more teen-age pregnancies.

12. STDs are the leading infectious diseases.
There is more substance abuse, and the
criminal justice system is one of the best
growth industries in America.

13. Through our clinical diligence, there are
fewer opportunistic infections.
But, there is more hepatitis C.

14. These issues which could set the stage for
another wave of HIV in our cities, and now more
than 15 years since discussions of societal
determinants of health were discussed by Dr.
Mann, have come to be the presenting problems
as we embark on our efforts to implement a
National HIV/AIDS Strategy - with one goal to
reduce new infections by 25% over the next 4
years. We are two years into the Strategy and
we have not made significant inroads.

15. If, we are to be instrumental in helping to
meet the goals of the National HIV
Strategy of the United States;
Then, finding, linking, and retaining hard to
reach populations should become a high
priority.
And, all factors (including medical and
non-medical or social issues) that are
barriers to the achievement of goals
should all get equal weight and attention.

17. Social and medical factors affecting individual and
community health are very prominent in the “hardto-reach target population”
There is poverty, joblessness, homelessness, and
despair.
Clients found to be living with HIV disease can
also present with substance abuse behaviors
and/or mental health conditions.

18. Within the AIDS Care Group
96% live at or below the federal poverty
line.
40% of clients have an incarceration
history.
35% have hepatitis C.
20% of the clients seen for medical care
and services do not have clean, safe, or
affordable housing.

19. The Hook is Food
Poverty and hunger are pervasive in
Chester’s central business district.
Without a poster advertising the opening
of the Drop-in-Center, the knowledge of a
morning breakfast center became instantly
well-known.
Clients came to expect that food and an
educator were on-site.

22. The distribution process was linked to
medical care. “Please come for food and
at the same time get all of your
immunizations up to date.” Staff were onhand all-day long to provide
immunizations, Paps, or other needed
health care services.

24. Transportation was added as a service in
1999.
As a resistor to care, transportation was
listed in the top three by clients.
AIDS Care Group staff found vehicles and
programs to support transportation
services.
Our motto became “We’ll come and get
you”.

26. The message has always been: “Know your
clients”.
Clients have grown with the agency.
The agency’s board is consumer driven.
Since the first board meeting in January, 1998
the president and one additional officer have
been consumers.
Clients are consumers, patients, staff members,
volunteers, peer educators, and ambassadors.
They help themselves, their families, and their
community.

27. Clinical Care
The AIDS Care Group was meant to be a
clinically-based organization.
It is now a clinical and social-services
based organization where the clinical care
division is busy due to efforts through
outreach to keep clients linked to their
providers.

29. Increase Access to Care and Improve
Health Outcomes for People Living with HIV:
– Establish a seamless system to immediately
link people to continuous and coordinated
quality care when they learn they are infected
with HIV.
– Support people living with HIV with cooccurring health conditions and those who
have challenges meeting their basic needs,
such as housing.

32. As clinicians in ambulatory settings we are
in the business of health; and we tell
patients, “go home to heal.”

33. When health care is oriented toward
doctors and hospitals, the natural tendency
is to hold them accountable. When the
responsibility gravitates toward the home,
who, but the patients are responsible for
preventing or managing disease? And who
gets blamed when they fail?

34. The outcomes of self-care include
quality of life, adherence, access to
care, and better attainment of signs of
improving biomarkers such as CD4,
viral load, and cognitive status.

35. Self-care, by definition, is a
multidimensional concept that refers to the
knowledge, attitudes, and behaviors that
clients develop, nurture, or perform to
manage a health problem or enhance a
health attribute. Instrumental in this model
are three identified components: the
patient, the provider, and the structural
setting (i.e. the home).

36. (Client) (Customer) (Consumer)
(Patient) as central to the strategic plan
to link persons to care
Who are our clients?
What do our customers want?
What do our consumers think about us?
What should our patients think about us?
How do we get there?

37. The Patient
HIV/AIDS epidemic continues to grow among
traditionally underserved and hard to reach communities.
Communities of color, women and substance users are
an increasing part of the HIV/AIDS epidemic.
Nationally, and particularly through CARE Act programs,
we are taking care of people whom society has
traditionally ignored: ex-offenders, the homeless, women
who are dependent on welfare, people with substance
abuse problems, and other disenfranchised communities
that have been affected with HIV/AIDS.
Patients enter into care with multiple co-morbid
conditions.

38. Uninsured Individuals by
Household Income

39. Multiple “Customers”
This makes the job even tougher
For instance, of all uninsured patients
– 11% are substance abusers
– 5% are homeless
– 2.5% are HIV positive
Johnson & Johnson / UCLA
Health Care Executive Program

40. “Census: Poverty rose by million”
Washington: The number of Americans in
poverty and without health insurance each rose
by more than 1 million in 2003, the Census
Bureau reported Thursday. The number of
Americans in poverty rose by 1.3 million to 35.9
million, or one in eight people (USA Today, August 2004). By
2010 the number of Americans living in poverty
had grown to 46.2 million. In 2013 one in six
Americans is living with food insecurities.

41. “A death sentence no more”
Jane Eisner, The Philadelphia Inquirer, Sunday, September 5, 2004
Many fatal diseases have become
treatable conditions that people can live
with for years. But the progress brings
ethical and social challenges. Diseases
such as diabetes, cancer, Alzheimer’s, and
AIDS will no longer be considered an
immediate death sentence.

42. Today, a 22 year old male living with HIV
is expected to live an additional 57 years;
to have a life expectancy of 77 years
(Anthony Fauci, MD at the IAC 2012)

43. Structural Issues - The Setting
Surprisingly, not much is being done to improve
the socioeconomic dimension of self-care such
as the settings, outside of the outpatient setting.
Housing is not usually a “provided service” in the
outpatient setting.
As a result, patients are empowered with great
knowledge and skills, but left to go back on the
streets – facing a multiplicity of setting problems
such as food or housing instability.

44. National HIV/AIDS Strategy of the United States-2010
Strategies built upon:
2007-Initiative by the Special Projects of National
Significance
Social Determinants of Health
Poverty
Crime
Housing, food, and employment insecurities
Threats of substance abuse
Structural, provider, and client inputs regarding
access to health care and health

45. The Simple Description to Finding,
Linking, and Retaining Clients in Care:
Hands-on
Service Oriented
Small Scale
Dependent on Intensive Medical and
Social Service Case Management

46. Complicating a Simple Description
Services, for instance, may need to be targeted to
county jails.
Prisoners known to be living with HIV disease will need
re-integration services.
Prisoners should ideally be identified before release to
effectively plan for and carry out comprehensive
discharge and reintegration services.
Outreach staff should utilize psychosocial, substance
abuse, and psychiatric assessments; intensive case
management; transportation, food, and shelter
assistance; and phone cards during the reintegration
process to help insure adherence to HIV medical care
and reduce recidivism.

47. Reality check:
No Identification
No birth certificate
No insurance
No housing
Where do you start with relapse
prevention facing protracted obstacles like
these?

48. Can clinicians deal with these urgent
problems (needs/demands)?:
Lack of available jobs
ID
Housing instability
Food insecurities

49. Linkage to Social Support Services:
Are They Case Management or
Clinical Management Issues?
Why is Case Management (Patient
Navigation) often the “horse pulling the
cart?”
Determine the functional level of the client;
then ask:
Would clinicians have patients to serve if
there were no patient navigators keeping
clients in care?

50. Our work in linking clients into care; and
retaining clients in a comprehensive and
adherent HIV clinical program, is only as
good as the weakest link.

51. SO WHAT????
Is the presence of outreach services;
patient navigation or case management
the solution to finding, linking, and
retaining clients into durable and adherent
HIV medical care?

52. Juggling Needs
Client needs
Provider needs

53. Formal and Learned Provider View
of Client Needs
1. Housing
2. Transportation
3. Food
4. Medical care
5. Clothing
6. Identification
7. Benefits

54. CLIENT NEEDS – as perceived by
the client
SEX
Cigarettes
Drugs – or old behaviors
Food
Housing
Transportation
SEX
Phone
SEX
Identification
Benefits
Medical care

55. BALANCING NEEDS

56. Develop relationships that keep clients
linked into social services
Meet people on their turf, drive them to
appointments of all types (medical, SSI,
court appearances)
Address acute needs with great intensity
and then transition clients into a more
chronic model when it’s appropriate
Be creative and persevere

57. Expected Challenges
– Cultures, subcultures, and politics
– Disease stigma
– Poverty, discrimination, addiction and
surviving the streets in the communities in
which hard to find and link populations reside.
– Identifying and meeting the unique needs of
each individual that is targeted for care
services

58. Addressing the challenges
– Identify barriers unique to each client
– Use multiple service providers capable of
addressing barriers
– Link care through patient navigators to help
insure the development and continuity of
success during outreach, linkage, and
retention efforts
– Keep it real

59. Outreach Team Members
Community and/or jail liaisons
Case managers and/or patient navigators
Housing specialists
Drivers
Medical team
A supportive administration

60. Developing and Sustaining a
Program
Historical development of services
Transitional phase to expand, improve,
and evaluate service delivery system

61. Know Your Community
Chester is the third poorest city of its size in the
nation; the city with the highest crime rate in its
county; and the county with the third highest
incidence rate of HIV disease in the state.

62. Know Your Target Population
20% of the clients seen for medical care
and services do not have clean, safe, or
affordable housing.
40% have had an incarceration history.
All of the patients have experienced or
continue to experience poverty.

63. Sustainability
 Go through the doors that have been opened.
Work beyond structural issues.
 Help agency staff to become fluent in “jails” and
“prisons”; in “shelters”; in “drug and alcohol
treatment centers”; in “probation and parole”; in
societal settings that have no time, energy, or
capacity to work with “hard-to-find, link, and
retain” populations.

66. Social Marketing Outreach Methods:
Project STYLE



Lisa Hightow-Weidman, MD, MPH
Associate Professor of Medicine
University of North Carolina at Chapel Hill

67. (Strength through Youth Livin’ Empowered)

68. DETECTION OF OUTBREAK
 November 2002: North Carolina began screening for acute HIV
infection

Acute HIV: defined as antibody-negative, RNA positive

Used robotic pooling, rapid notification, and confirmatory testing
 In early 2003, of 5 acute infections detected within the first 3 months, 2
were young Black MSM attending college in the Triangle
 Only report of HIV among college students prior to this showed very
low HIV prevalence

69. RETROSPECTIVE REVIEW OF STATE
EPIDEMIOLOGIC DATA (JAN 2000-APRIL 2005)

70. COLLEGE VS NON-COLLEGE
JANUARY 2000-APRIL 2005
Number of Cases
250
200
150
College
Noncollege
100
50
0
2000
2001
2002
2003
Year of Diagnosis
2004
JanApril
2005

71. COLLEGE CASES
JANUARY 2000-APRIL 2005
Number of Cases
60
50
40
30
College cases
20
10
0
2000
2001
2002
2003
Year of Diagnosis
2004
JanApril
2005

72. 157 COLLEGE STUDENTS
133 African American
(84.7%)
79 Male sex partners
44 Male and female 6 Female sex partners
(59.4%)
sex partners
(4.5%)
(33.1%)

73. THE YMSM OF COLOR SPNS
INITIATIVE
 The Initiative funded in Fall 2004, with five year grants
 Eight Demonstration sites
 Develop, implement, and evaluate innovative models of care for
Young MSM of color
 Apply intervention models that identify, engage, link, and retain
HIV-infected individuals in care
 One Evaluation Center (GWU YES Center)
 Support intervention and local evaluation efforts of grantees, with
capacity building, TA, and training
 Conduct comprehensive, multi-site program evaluation

74. SPNS DEMONSTRATION SITES

75. STYLE PROJECT GOALS
 Goal 1: Increase identification, testing and enrollment in
enhanced HIV services for young MSM of color at risk
for or infected with HIV in North Carolina
 Goal 2: Improve linkage to and retention in care for
HIV+ clients
 Goal 3: Provide quality care and prevention messages
for young sero-positive MSM of color

76. STYLE SERVICES OVERVIEW
 Clinical care for Young HIV+ MSM
 Focus on linking to care and retention in care
 HIV care provided at 2 local clinics by staff physician
 Support and Client Services
 Case management (AAS-C)
 2 weekly support groups for HIV+ Black Men
 One-on-one support by outreach staff
 Rapid HIV Counseling and Testing (Venue based/College Tour)
 Outreach and education in the community
 HIVSTD 101/HIV in the Black Community
 Social Marketing
 Health Fairs/Community Events/Pride
 Healthcare provider training on LGBTQ issues
 LGBTQ Resource Guide

77. SOCIAL MARKETING CAMPAIGN
 #1: Decide goals of campaign and target
audience
 Locations: college campuses and community
 Goal: increase HIV testing among young men
who have sex with men of color
 Medium: print based with website for more
information
 This was 2006

78. SOCIAL MARKETING CAMPAIGN
 #2: Recognize the need for collaborations
 Collaborated with a social marketing company
(Better World Advertising) to conduct formative
research to inform message development and
campaign materials

79. SOCIAL MARKETING CAMPAIGN
 #3: Conduct formative research
 Conducted focus groups with Young Black MSM
and interviews with other key stakeholders
(college administrators, student health workers,
community partners)
 Presented ideas for media campaign

80. THE LOGO

81. Ad #1

82. Ad #2

83. The Chosen Campaign

84. The Chosen Campaign

85. STYLE CORE COMPONENT:
TESTING
 College/Venue based Rapid HIV testing tour
 Over 3000 NC college students tested

10 new positives identified and linked to care
 Mix of schools (Duke, UNC-Chapel Hill, NC State, NC Central,
Shaw, St. Augustine’s, Livingstone) also includes testing events at
churches
 Youthful testing staff, buy-in from campus groups drives high
turnout (as many as 250 students at an event)
 Core component is confidentiality for positive clients (space/
logistics)
 MD on site/on call of immediate linkage to confirmatory testing and
care

86. TESTING TOUR ART INSTALLATION

87. OUTCOMES
 81 HIV-infected YMSM of color were enrolled in STYLE.
 The mean age of the sample was 21 years; 83%
identified as black and 11% as Latino.
 Two thirds of the cohort was newly diagnosed.
 85% of STYLE clients attended at least one primary care
visit in each 6-month period over a 2-year span

88. MOVING FORWARD:
HARNESSING THE POWER OF SOCIAL MEDIA

89. Outreach in 2013
PHEED
Early 2000s Outreach

90. Social media landscape is “dynamic”

91. CAN SOCIAL MEDIA LEAD TO
SOCIAL GOOD?
What
determines?
Like
Share
Unlike
Move
on/ignore

92. CONCLUDING THOUGHTS
 Important to identify the goals, target population
and media platform for your social marketing
campaign
 Formative work with all key stakeholders is critical
 What you want may not be what they want,
need or will use
 Be forward thinking of the current “venues” where
the target population can be reached.

93. Q&A
To sign up to receive emails about other IHIP
products and Webinars, email Sarah Cook-Raymond
of Impact Marketing + Communications at
scook@impactmc.net