Latino Leaders Bringing Respect, Medical Care and Housing to HIV Services for People Who Use Drugs
Thirty-seven years ago, Jose Davila was working his first job, at Lincoln Hospital in the Bronx in New York City. And he didn't like what he saw.
"I'm Puerto Rican and saw how disrespectfully my people were being treated if they were drug users," says Davila. "It made me angry, so I made a commitment to serve this community because no one else was."
Today, Davila is the president and chief executive officer of BOOM!Health, a harm reduction center right across the street from his former employer. BOOM!Health offers everything from primary and mental health care to laundry and three meals a day -- all of it free of charge. BOOM!Health is working in the South Bronx, the area with the city's highest rates of HIV, drug use, poverty and homelessness. BOOM!Health was created two years ago, when two older organizations, Bronx AIDS Services and CitiWide Harm Reduction, decided to merge and combine their resources in an effort to offer their clients a full range of holistic services that better meet their health and harm reduction needs.
Three months ago and a hundred miles away, Prevention Point Philadelphia (PPP) moved to a well-lit former church nearly five times the size of the cramped dark basement space in which it had been providing harm reduction, health, outreach and social support services to people who inject drugs (PWID). In the short time since its move, PPP has increased by one-third the number of people it serves in the Philadelphia zip code claiming the city's highest rates of poverty and drug use. It plans to continue to expand its clientele and the variety of services it can provide, including hepatitis C treatment.
"Harm reduction organizations can't continue to exist in a silo," says Jose Benitez, executive director of PPP. "We started out just providing syringe services but kept hearing that other services -- like free, respectful medical care, housing services that don't exclude active drug users, and overdose prevention -- were what people really needed the most." BOOM!Health's Davila agrees, adding, "You can't think about changing your injection drug behavior or taking medications for HIV if you don't have roof over your head or food on your plate."
Most syringe service programs (SSPs) in the U.S. offer some kind of counseling and/or health care referral services in addition to clean syringes, but since they often have to grapple with inadequate, targeted funding, their ability to diversify has been limited. Now, the Affordable Care Act -- with its focus on reaching high-health-need individuals through community health centers that offer holistic care models -- and recent pledges to end AIDS by national (and some state) government representatives are providing new opportunities for harm reduction organizations to better serve PWID by offering syringe services as just one piece of a holistic care package.
PPP and BOOM!Health are at the forefront of this effort, and the model they can provide for other organizations throughout the country is increasingly crucial. Throughout the nation, rates of injection drug use are skyrocketing, with heroin use rising nearly 150% between 2007 and 2013, with some of the largest increases in rural areas that do not have SSPs or other infrastructure to deal with addiction or the resulting surges in HIV or hepatitis C.
Benitez and Davila, both Puerto Rican, are ensuring that their organizations meet the needs of Latinos, who remain underserved by public health and harm reduction efforts alike. Latinos are the largest minority group in U.S., but have the nation's lowest rates of health insurance coverage. In New York, where Medicaid was expanded under the Affordable Care Act, the rate of uninsured Latinos has started to drop precipitously. However, Pennsylvania did not expand coverage until this year, when Democratic governor Tom Wolf took office, so the impact there remains to be seen.
Over half of BOOM!Health's clients are Latino. Benitez says that since PPP began hiring bilingual staff shortly after he took over eight years ago, the percentage of Latino clients has risen from 8% to 24%. Many of the Latino clients frequenting both organizations speak only Spanish, adding to the already substantial barriers to accessing health care that PWID of all ethnicities regularly experience at other facilities.
"Just navigating the health care system is a deterrent for accessing care for someone not familiar with it," says Ed Manchess, director of harm reduction services at BOOM!Health. "And then you also have the stigma and discrimination towards PWID in various hospitals and clinics, which we see all the time, that keeps people away."
Many of the Latino clients seen by BOOM!Health and PPP come from Puerto Rico. On the island, SSPs and harm reduction services are nearly non-existent, the rate of new HIV infections is nearly double that in mainland U.S. and 50% of new HIV infections are among PWID (compared to about 10% in the rest of the U.S.).
Access to sterile syringes also remains limited in mainland U.S. The U.S. Congress has banned the use of federal money to fund SSPs since 1988 (the ban was briefly lifted in 2009, before Congress reinstated in 2011), and thus all syringe services must be funded by cities and states. Despite much evidence that SSPs reduce disease transmission without increasing drug use, many state and local governments still refuse to support them.
In New York City, both the city and state have supported widespread SSPs since the '90s. The proportion of the city's new HIV infections among PWID has dropped to just 4.4% in 2012. In 2014, New York Governor Andrew Cuomo became the nation's first governor to issue a plan to end AIDS in his state -- with support for SSPs and further reduction of infections among PWIDs being key parts of his blueprint.
In Philadelphia, stigma against people who use drugs can increase jitteriness among funders and sometimes require hours of negotiations, despite the clear need to provide them services. This has left PPP as the only sanctioned, full-service SSP in a city of over 1.5 million, yet scrambling from year to year to scrape together funding. Despite this, since its founding in 1992, PPP has helped drive down the percentage of HIV infections among PWID in Philadelphia. In 2013, injection drug use accounted for less than 6% of newly-diagnosed HIV cases, as reported by the city's AIDS Activities Coordinating Office (AACO).
"This is positive proof that this model of reduction is successful and saves lives," says Jose DeMarco from ACT UP Philadelphia. "Jose's non-judgmental and welcoming approach to participants makes Prevention Point an inviting organization that PWID actively seek out for services -- a lighthouse in a very dark place."
The federal funding ban also means that it is difficult for harm reduction programs, including PPP, to obtain any Medicaid reimbursements or other federal funds for their general health care services -- not just syringe services. Benitez hopes that the Medicaid expansion in Pennsylvania may start to change that by allowing PPP to expand the free clinical and housing services it provides. He has been meeting frequently with representatives from the state health department and reports that Governor Wolf is planning to announce a plan to end AIDS in Pennsylvania and "seems open to nontraditional kinds of health services, like SSPs," as part of that plan.
Despite the ban and the limited Medicaid reimbursements it can receive, BOOM!Health has developed an innovative and highly effective co-location model for providing a one-stop shop for holistic care. Clients enter the BOOM!Health harm reduction center on the ground floor, where they can obtain clean syringes and condoms, make free long distance phone calls, pick up mail if they don't have a permanent address, do laundry and even take a shower.
BOOM!Health's second floor houses Brightpoint Health, an independent, federally qualified health care provider that receives a high rate of Medicaid reimbursement, where patients can receive health care services and walk down the hall to Evers, an independent pharmacy, to get their subscriptions filled. In the third-floor drop-in center, clients can relax on benches or access free Internet, get a haircut at designated times, and attend group counseling sessions. Like BOOM!Health, PPP also offers a drop-in center and immediate linkages to care, along with mail and phone services.
"The care here is non-judgmental and compassionate and looks at drug users as a whole person, and that respect helps empower them to make changes, if they so choose," says Manchess.
Samuel Santiago first visited BOOM!Health, then called CitiWide, in 2010, shortly after he was released from prison. "When I first came here I was a user, and I don't use anything now," he says. "This is a place of tranquility where you can forget about the streets for a while and motivate yourself to do something, even if it's just to hear somebody talk in a group, because you might hear something that will click, and it can change your whole life."
Lucile Scott is a writer living in Brooklyn, New York, who has written extensively about the global and domestic AIDS epidemics for POZ magazine and organizations including amfAR and Housing Works.