In Georgia's Metropolitan Heart, HIV Beats On
A Snapshot of Cobb, DeKalb, Fulton, and Gwinnett Counties, Targets of the U.S. "Ending the HIV Epidemic" Plan
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 and seven states 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 following is the first of our snapshots.
The Big Picture: HIV in Cobb, DeKalb, Fulton, and Gwinnett Counties
Georgia's Greater Atlanta area is a vibrant national mecca for gay black men, but inequities in health, housing, and employment make it the community facing the biggest HIV prevention and care gap.
Need-to-Know Stats About HIV in Greater Atlanta
About 37,000 people amid metropolitan Atlanta's population of 5.9 million are living with HIV, 80% of them men (mostly who have sex with men) and 70% of them black.
The area has had about 1,500 new HIV diagnoses annually for the past five years, with 17% also having an AIDS diagnosis within three months of the initial diagnosis.
Fulton County contains most of central Atlanta -- and the majority of HIV cases in both the metro region and the state of Georgia.
Because of a new needs formula, Atlanta (along with Augusta, Georgia; Baton Rouge, Louisiana; and Memphis, Tennessee) is facing a reduction of 29% to 56% in funding over the next few years from the federal HOPWA (Housing Opportunities for Persons With AIDS) program.
Successes and Challenges Facing HIV Care and Service Providers in Greater Atlanta
Nicole Roebuck: I've been E.D. [executive director] here since 2016 and before that was director of client services since 2000. I started out working in the HIV field in New York City prior to that, as a social worker.
AID Atlanta has been around since 1982, founded by a group of folks whose friends were suddenly getting this weird disease. They founded a small call center with volunteers and helped people die with dignity. Then the group evolved and got money from the Robert Wood Johnson and Woodruff foundations, got early Ryan White CARE Act dollars, and got state money to run the state HIV/AIDS info hotline. So 37 years later, we're a comprehensive agency with two health centers, one here in midtown Atlanta and the other in Newnan, Georgia, a rural area.
We have about 2,600 people now in HIV treatment and care and another 200 getting PrEP [pre-exposure prophylaxis] services. We do mental health case management, care coordination and linkage to care, ADAP [AIDS Drug Assistance Program], and housing assistance. We also do free HIV and STI [sexually transmitted infection] testing and STI treatment, with no appointments needed. And through our partnership with AIDS Healthcare Foundation (AHF), which has been our fiscal parent since 2015, we have two pharmacies on site. So we're a one-stop shop, even though we're still working on being able to have our ADAP clients fill their scripts at our pharmacies so they don't have to go to different pharmacies.
Having AHF as our fiscal parent has been a huge plus, because in the past we were so heavily reliant on Ryan White or grant funding, and we couldn't add new Ryan White patients if we didn't have the money. Now we can.
Easily 80% of our clients are African American and male, with the majority men who have sex with men. We have about 20% female clients, about 2% to 3% transgender, and about 4% to 5% Hispanic and other.
Tim Murphy: Describe Greater Atlanta's current moment with HIV/AIDS.
NR: We don't know the treatment cascade rates specific to the Atlanta area, but it makes up the bulk of all HIV cases in the state, where you see that, as of 2017, we're linking 82% of all HIV diagnoses to care, but then you see a dropoff in terms of retention in care and viral suppression, which was at 62%. So we have to work on that.
We have a lot of different ways of trying to make sure that people are retained in care, such as electronic appointment reminders via text or email. We also have a team that calls people who have not had an appointment in the last 104 days. And we give [free transit] cards and have a contract with Uber health, which gives reliable rides to patients and caregivers. But we still struggle with the transient nature of our members. Their cell service gets canceled, addresses and phone numbers change from month to month, and sometimes people just drop off the grid.
TM: How is your PrEP program going?
NR: We have movement on PrEP, but we're still struggling with how to get more black gay men on it.
Tim Webb: The community is getting more and more open to the idea of PrEP, but we still struggle with getting PrEP to a community without resources. We can connect people to the drug and doctors, but the long-term price of having labs done every three months [is a challenge]. We cover labs for people in our PrEP program, but you can only do so much with the dollars. Thankfully, as of the moment, we don't have a waiting list for PrEP.
NR: Tim really hit the nail on the head. We've done aggressive awareness campaigns regarding PrEP, but there are not enough dollars following. Our first program was funded by Gilead [which makes Truvada (FTC/tenofovir disoproxil fumarate), used for PrEP], a grant that we stretched until we simply could not anymore in terms of lab dollars. CDC [Centers for Disease Control and Prevention] and HRSA [Health Resources and Services Administration] don't pay for this. White gay men tend to have private or job-linked insurance, as opposed to most of our population.
TM: Where else are you hitting the wall?
NR: We really need to address those so-called social determinants of care, those additional issues that people have to contend with. We're a state that has chosen not to expand Medicaid, but now we're moving toward a waiver program that would give Medicaid more flexibility. It's a step in the right direction short of full expansion, and right now in Georgia, we'll take anything.
Then there are the issues of poverty, education, and employment -- all the things that help people live and be productive citizens. There's poverty, racism, stigma. All these things need to be addressed in a more structural way. Does it take funds to do that? Absolutely.
TM: Let's talk about housing a little.
NR: It's a huge problem for low-income folks in greater Atlanta, because affordable housing options are few and far between. Plus, Atlanta is facing up to a 60% reduction in HOPWA funding over the next few years, after the passage of the 2016 HOPWA Modernization Act, which changed the formula from counting all dead and living cases to simply all living cases.
TM: Tell me a story that illustrates either your successes or your challenges.
NR: In a general sense, if people here test HIV positive, then we move them immediately into peer navigation, get them an appointment immediately at the clinic, tell them it isn't a death sentence anymore. We've had people come in and test positive with fewer than 200 CD4s and see them get up to 500 CD4s in a month. Treatment works if you have a support system in place.
TM: What are some goals for the next 12 months?
NR: I would really like to see people living with HIV standing up more, acting up and demanding change, such as [for] Medicaid expansion in Georgia.
TM: Does AID Atlanta have an advocacy department that mobilizes clients for rallies, protests, initiatives, etc.?
NR: We use AHF for that. In his other life, Tim is a community mobilizer for AHF.
TW: We've done several mobilizations in and outside Atlanta around access to things like PrEP, needle exchange, and more housing. We need to normalize HIV more and stop the shame around it, show commercials with real people on HIV treatment. Last Saturday, we started a five-city road tour talking about HIV and STI transmission and human trafficking in Georgia. We had about 125 people come out to be educated in rural areas. We partner with the local Boys and Girls Clubs, which give us a free facility where we offer tests and free groceries to get people to come in.
Positive POV: Tim Webb
Webb, a 32-year-old peer educator with AID Atlanta, has lived in the area since 2011. He was diagnosed with HIV in 2010.
TW: A lot of times, people fall apart right after they are diagnosed, so I'm here to say, "Hey, I got you -- we're here with you through the whole process." And it's great when you have people come back to you and say, "Thank you for being there, pushing me, calling me at night, answering my calls at 10:30 p.m. or midnight, even 90 days after diagnosis." People remember those who took care of them, so I'm happy to help people realize that HIV isn't a death sentence and that you can live and thrive.
TM: What's been most challenging for you personally about living with HIV?
TW: Moving from Philadelphia to Atlanta and trying to navigate the system and not necessarily knowing where to go. My fiancé and I moved here wanting a fresh start, because Atlanta is a black mecca. But it was actually hard to find resources. I started at AID Atlanta as a client.
TM: Did AID Atlanta help you navigate the transition?
TW: Yes, but I had done some of my own research, so I challenged the forces against me and decided to get a job in this field so that others coming down the line didn't have to go through this.
TM: Is it easy for you to live with HIV?
TW: Oh, yes. Once I accepted my own status, I decided I wanted to be able to say to people, "I'm an example of a black gay man thriving in the South with my HIV virally suppressed, and you can be, too."
TM: What needs to be done to reverse HIV rates among black gay men in the South?
TW: The main thing is mental health. We need to address the whole body, mind, and soul.