Even in One of the Most Affluent Counties in Maryland, HIV Impacts the Most Vulnerable

In light of the federal government plan announced in February 2019 to end the HIV epidemic in the U.S., TheBody has created a new series called Eyes on the End. This series will include a snapshot of the HIV epidemic in each of the 48 counties, seven states, and two cities targeted within the plan. These profiles aren’t meant to be the definitive story of the epidemic in each locale, but rather—through sharing some basic statistics and interviews with a few key stakeholders—to provide some context for what’s occurring there, and what it will take to end the epidemic in that area.

The Big Picture: HIV in Montgomery County, Maryland

Maryland’s D.C. suburbs are known as affluent, but they’re also currently writing an Ending the Epidemic plan to reach communities vulnerable to HIV: low-income folks, African immigrants, and men of color who have sex with men.

Need-to-Know Stats About HIV in Montgomery County, Maryland

• New annual HIV diagnoses in the county have plunged from an all-time high of 325 in 2007 to about 160 in 2017. That year, 120 diagnoses were in men, and about 43 were in women.
• That same year, African Americans made up nearly 60% of all new cases, more than twice the number of diagnoses in white or Latinx people. (That proportion reflects prior years as well.)
• In recent years, new infections via heterosexual sex have equaled or exceeded those via male-to-male sex—an exception to a national pattern.
• Among people diagnosed with HIV in 2017, 89% were linked to care within three months. That same year, among all people living with HIV/AIDS in the county, 56.5% were virally suppressed.
• Among county zip codes, 20906 (Aspen Hill) had the only percentage of new HIV cases in 2017 in the double digits—16%. The same zip code ranked in the county’s bottom five for various markers of prosperity and health.
• In 2017, a quarter of new HIV diagnoses were in foreign-born residents, the vast majority of them from Africa.

Successes and Challenges Facing HIV Service Providers in Montgomery County

We talked with Melvin Cauthen, supervisory social worker and program manager for client services at the county health department’s Dennis Avenue Health Center in Silver Spring, the county’s only Ryan White–funded health and services provider.

Melvin Cauthen: I’ve been in my current role since 2014, and at the center since 2010 as a social-work case manager. Before that, I worked in the foster-care system for two years. I’m HIV negative, but my best friend from grade school, best friend from high school, and best friend from college all died of AIDS. So that was my personal connection to HIV.

Tim Murphy: That’s a strong connection. Tell us about the Dennis Avenue center.

MC: We started in 1988, when the demographic was mainly gay white men. Now it’s a completely different demographic. The biggest explosion in services we’ve had since I’ve been here is housing, rental assistance. That’s gone from 10%, 15% of my job to 25%.

Our Ryan White budget is $2.5 million, and our total budget is $4.5 million. Our staff is 45 to 50 people. The staff resembles the clientele, which is majority minority. We have openly HIV-positive and openly LGBTQ people on staff, currently no transgender or nonbinary staff that I know of. We have staffers who speak our clients’ four main languages, which are English, French, Spanish, and Amharic, the native language of Ethiopia, where many of our clients are from.

Client-wise, we see about 850 people a year across all services. As of July 2018, the clients were half men, half women, and a very small number of transgender or nonbinary. About a quarter of the clients are men who have sex with men. About 58% are African American or Africa-born, and 25% Hispanic, with other races making up the rest. About half the clients are over age 55. We have a very large African population of clients, most of whom got HIV and/or were diagnosed in their birth countries. We’re about 65% immigrant.

As for services, we have HIV primary care and medical and non-medical case management, substance use and mental health counseling, housing supportive services, dental care, and full STI testing and treatment, as well as PrEP [pre-exposure prophylaxis] services. Currently, we have fewer than 50 people on PrEP—often the HIV-negative partners of positive heterosexual clients.

We also provide transportation, food cards to local grocery stores, and linkage to county services for employment and ESL.

We don’t have our own housing facility, but with HOPWA funds, we offer both permanent placement and rental assistance up to 21 weeks. We also use Ryan White Part B funds for rental assistance, including paying for and helping to find rooms for clients who can’t rent a place in their own name because of their incarceration and/or bad credit history.

TM: What is the HIV situation like in Montgomery County?

MC: We’re the D.C. suburbs, so we’re a very expensive county, with rents in some zip codes higher than in others. Most of our clients are from Silver Spring, Germantown, and Gaithersburg. In 2018, we saw the lowest number of new HIV diagnoses in 30 years, which follows a trend of a 4% decrease every year since 2011. Probably the one area where rates are flat, and maybe even going up, are in men who have sex with men (MSM) of color, Black and Hispanic. That’s been a very difficult population for us to connect with, to get and keep in treatment, or to get on PrEP.

Our county is currently writing an Ending the Epidemic plan, which should be out by summer or fall 2020, and one of the things we’re looking at is doing more PrEP promotion over the gay hookup apps like Grindr and Scruff, as well as building more coalitions with private providers around HIV testing, PrEP, etc.

TM: Have you heard of immigrant clients fearful of seeking services for fear that, per Trump’s proposed [soon to be in effect] “public charge” rule, they will be denied green cards?

MC: I don’t know of anyone who’s not come in, but it’s certainly affected clients’ mental health. We know of families who’ve moved neighborhoods because ICE [Immigration and Customs Enforcement, which conducts deportation raids] was in their area.

TM: Where have you had the most success?

MC: Clients who come here for care do very well. We have an almost 90% rate of viral suppression. The problem is when people get private insurance through a job or through Obamacare, they often move on to a private provider, and then their case management here becomes optional, so we can’t track their progress.

The other area of success is rental assistance. We’re currently assisting more than 80 families, twice the level of 2014. That might mean paying a portion of someone’s rent for a studio or room, or paying nearly all of a $2,000 rent for a family’s three-bedroom apartment. We do that with about $1 million from HOPWA, but also about $225,000 from Ryan White.

TM: Where do you feel most frustrated or challenged?

MC: Probably not being able to identify folks out there who are positive and either not diagnosed or not in care. Doing better on that is going to be part of our Ending the Epidemic plan. We need to institute universal testing, so everyone who goes to a place where labs are done, such as providers’ offices or the ER, is tested for HIV, with an opt-out clause.

TM: What would you do with unrestricted new funding?

MC: Open a satellite center in Germantown or Gaithersburg so folks living there don’t have to travel by bus to Silver Spring. I’d also do more educating out in the mainstream about U=U [the fact that those with HIV who are on meds and undetectable are unable to transmit the virus to others sexually] or PrEP. Remember the campaigns from back in the day, like, “This is your brain on drugs” or “A mind is a terrible thing to waste”? I would like U=U to be that familiar.

TM: Can you share any stories that illustrate the work you do?

MC: We had a client, an alcoholic Latino gentleman who went from the hospital to the street for years. We were able to get him a room where he lived for close to two years. He’s now in a real apartment, and he’s no longer drinking. So housing really was treatment to him, because once he had it, the other pieces fell into place.

We also have an African-American male client who was severely alcoholic but then finally went into rehab, then into a sober house. Then we got him into permanent HOPWA-funded housing. Recently, he took a course to be a certified nursing assistant, and now he’s gainfully employed for the first time in a long time.

I think both stories show the importance of housing. If someone can just make it to our door, we got ’em [in terms of connecting them to the things they need].

Positive POV: Maureen Deely

We spoke with Maureen Deely, RN, 59, of Germantown, Maryland, a nurse at the Dennis Avenue Health Center, who was diagnosed with HIV in 1986.

Maureen Deely: I grew up in this area. I was a wild child, one of those people who bucks authority. As a child, I was abused by a couple of neighbors, which makes people act out with drugs and alcohol, which I did.

In 1986, I hit my bottom and my sister suggested that I get tested for HIV, so I did, at the county health department. I waited for the results for two weeks, and then a nice man at the department told me I tested positive. I don’t know if I got it from sex, injection drugs, or a needle-stick at work, as I was already working as a nurse, but I was shocked. I thought I’d be dead in a week.

The health department had a fledgling support group for people living with HIV/AIDS, so I went. For a while, I was the only woman there—it was primarily, but not all, gay men.

Then I realized, well, I have my nursing degree, and who better to take care of people with HIV than someone with HIV? This was when nurses were leaving HIV-positive patients’ food trays outside their rooms, not wanting to touch them. So I worked for an agency that did home care for people with AIDS. Then when this clinic started, they asked me if I wanted to work here even though they didn’t know I was positive. I waited a year, then told the director. She was great about it. Then piece by piece, I told people here. I’d say, “Just to let you know, I’m HIV positive.”

I also started the [now-defunct] hospice program here. You would get to know someone extremely well, and then they would pass away, but I gave my all and did as much for them as I could. I would yell a lot, because things like bedside commodes were not being delivered on time.

I also joined the national Women’s Interagency HIV Study (WIHS) as both a patient/subject and a member of the community advisory board. This was in the early ’90s, before it even opened to patients—I was part of the planning process. And I joined the D.C. metropolitan area HIV/AIDS planning council, on the committee that covered taking care of people living with HIV, so I could lend my medical experience to it. I also started facilitating support groups for people living with HIV/AIDS, and I still facilitate one here, to this day.

I’ve never been sick with HIV complications. I’ve been blessed.

Tim Murphy: What is a typical workday like for you at the clinic?

MD: I do a lot of home visits. Mornings, I come in and see how my patients are doing. I do a lot of education, especially to newly diagnosed patients who feel like they’re gonna die tomorrow, because people still feel like that. So I tell them I’m positive. Sometimes they don’t believe me, because I don’t “look” like I’m positive. I talk to them about options for having safe sex as positive people.

TM: What do you think needs to happen to end the HIV epidemic in Montgomery County?

MD: More education. People need to know they’re not going to keel over and die from having HIV or get it from a handshake. I wish we could do more testing, go into apartment complexes, knock on doors and offer to test people.

TM: What do you do for self-care and joy?

MD: Friends and family are my sources of love and support. Sometimes I go to 12-step meetings. I also read a lot—murder mysteries, sci fi, witches, things like that.

TM: What do you make of your life’s journey so far?

MD: Even though there’s been a lot of political infighting with HIV/AIDS, it’s been exciting, and I’ve always felt like I was making a difference in someone’s life, which is what really matters to me.