San Antonio Is Making Gains Toward Viral Suppression
A Snapshot of Bexar County, Texas, a Target 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 Big Picture: HIV in Bexar County, Texas
With its epidemic concentrated among Latinx men who have sex with men (MSM), San Antonio has taken an HIV hit in the past decade, but new efforts are turning the numbers around.
Need-to-Know Stats About HIV in Bexar County
- More than 6,000 of Bexar County's 2 million residents live with HIV. Of those 6,000, 85% of them are men and 63% are Latinx (19% of HIV-positive residents are non-Hispanic white; 16% are non-Hispanic black).
- The number of new HIV cases increased by more than 50% between 2006 and 2016.
- In 2017, six of 16 "clusters" of cases of genetically similar HIV in Texas were reported in San Antonio, primarily among Latinx men who have sex with men.
- Among the world's Fast-Track Cities working toward viral suppression among folks with HIV, San Antonio is now making progress. A study last year found that 86% of people living with HIV there were aware of their status, 72% of those diagnosed were connected to care, and 85% of those connected to care had an undetectable viral load.
Successes and Challenges Facing HIV Service Providers in Bexar County
We spoke with Howard Rogers, M.A., executive director at the Alamo Area Resource Center, an HIV/AIDS services agency in San Antonio.
Howard Rogers: I'm an HIV-negative gay man. I've been the E.D. here 15 years. I came from San Francisco, where I oversaw HIV housing and mental health services for Catholic Charities.
AARC started in 1990, but in the last decade we've grown a lot. In 2002, we adopted the one-stop-shop model, and now we have 14 different services, including a primary health clinic that not only specializes in HIV but in LGBTQ specialty care across the board. There are two other HIV agencies in town, San Antonio AIDS Foundation and BEAT AIDS, which focuses on the black community. They both have small clinics, but we're the only one with so many wraparound services.
We try to get people into care the very same day they are diagnosed with HIV, with the average time being withing seven days. The majority of our new cases are MSM of color between 18 and 35.
We also offer case management, outpatient individual and group counseling for mental health and substance abuse (based on a harm-reduction model), and psychiatrists (for prescribing) two days a week.
We give out bus passes, plus we have a van service to take people to and from appointments. And we also have intensive case management to get people with HIV who've fallen out of care back in. We provide housing placement for people and help them locate housing, and we provide rental assistance through HOPWA [Housing Opportunities for Persons With AIDS].
We also have a prevention and PrEP [pre-exposure prophylaxis] program. We do a lot of communication prevention, and we also probably test about 1,500 people a year. Currently, we have about 85 people on PrEP. We have an on-site pharmacy, so if someone has insurance, we'll bill them, but if not, we'll use funds from our Medicaid 340B program (Editor's Note: read an explanation of 340B here) to fund their PrEP.
We also have a health insurance program where we provide payments for people's premiums, copays, and deductibles on their employer plans or independent Obamacare plans. That's about $1.3 million a year, out of a $10 million budget, which comes out of 340B proceeds. This is highly needed in our state, because Texas has the highest rate of uninsured people in the country -- about 19% of all those under 65. Texas ADAP [AIDS Drug Assistance Program] pays only for HIV meds, not for full health plans, and Texas also is among states that have chosen not to expand Medicaid eligibility under Obamacare.
We have about 1,600 clients living with HIV, and another 1,500 in our prevention program. About 77% of our clients are male. Forty percent identify as gay or bi, but 41% of those who identify as hetero are also men who have sex with men (Editor's Note: a reminder that not all MSM identify as gay or bi). About 2% of our clients are transgender, 63% Latinx, 20% African American, about 18% to 19% white. About 10% to 20% of our clients are undocumented.
Of our staff of 47, 30% to 40% identify as LGBT, 60% are Latinx, including many people in leadership positions, 25% are white, and the rest are African American. We also have several HIV-positive and two transgender people on staff, so we're fairly diverse.
Tim Murphy: Tell us about San Antonio's participation in the global Fast-Track Cities movement, in which cities aim to get their population of folks living with HIV up to 90% on three markers: knowing their status, in care and on treatment, and virally suppressed.
HR: AARC participates in a group of community stakeholders called End Stigma End HIV/AIDS (ESEHA), which meets monthly to promote and coordinate efforts to reach the 90-90-90 goal. As of March 2019, San Antonio's numbers are: 82% of those with HIV have been identified, 86% of those identified with HIV are in medical care, and 78% of those in medical care are virally suppressed. At our own clinic, 93% of those in care for HIV are virally suppressed. We are very proud of this achievement and attribute this to our one-stop-shop, wraparound model of care.
TM: Tell us a little about your LGBTQ specialty clinic.
HR: It started three years ago as my brainchild, because as a gay man I'm keenly aware of the barriers we face walking into a doctor's office and having them make wrong assumptions about who we are and our lifestyle. I wanted to create a clinic where LGBTQ individuals could receive culturally competent care from entry to exit. We got some help from the Elton John AIDS Foundation with the startup costs, and also help from Fenway Health in Boston and the LA LGBT Center. We do everything from anal Paps to transgender hormone therapy, and we work with UT [University of Texas] Medical San Antonio, which provides clinics twice a month to treat people who are uninsured for free.
But it's still been challenging. We have a contingent of people who don't want to come to a clinic that's also where people get HIV care.
TM: If the Department of Health and Human Services (HHS) comes through with this HIV money for "hot-spot" HIV counties like yours, how would you use the money?
HR: We'd probably hire more mental health counselors. If you're in the LGBTQ community here but HIV negative, there are virtually no mental health resources for you. I'm not sure if we'd be able to use that HHS funding for that purpose, though. We also need more money to help people pay premiums, copays, and deductibles. That's a bottomless pit of need.
TM: Brag a bit about your successes.
HR: Definitely providing the one-stop-shop model. That's been the single biggest factor in our growth the past 10 to 12 years. And the LGBTQ specialty clinic.
TM: Where are you stuck?
HR: Our data is not as fresh as I would like, in terms of our prevention efforts. The county publishes data two years after they collect it. So we have to rely a lot on our own internal data. We have a data manager who does our reporting and writes our grants. Also, we need more mental health staff for HIV-negative clients in the LGBTQ clinic.
TM: Tell us a few stories.
HR: On a number of occasions, our outreach team goes into communities and seeks out people who have not been in care for the last year or two, finds them and works with them, literally on the streets, to find them the resources, like housing or substance treatment, to get them back into care. And we've had quite a few successes in terms of that.
We've also had a lot of very young people whose families discard them when they come out. So we work with them. We're fortunate to have a shelter in San Antonio for LGBTQ youth, so we'll refer them to it and work with those kids, particularly if they're positive, in helping them develop a support system to be able to go to school. Sometimes we do reconciliation counseling with family members. Last year, we had a 16 year old whose father threw him out. His grandmother was the only person who was sympathetic to him, so we brought her in to help the process of his going to live with her.
POSITIVE POV: Jacob Castrejana
Jacob Castrejana, 34, is an AARC case manager who helps his clients work through the paralyzing fear his own diagnosis brought him. He was diagnosed in 2007.
Jacob Castrejana: I was diagnosed in 2007. I was devastated -- it came out of nowhere. I knew I had engaged in risky sexual behavior, but I thought, "Oh, [HIV is a risk] for other people." First, a former sexual partner told me she'd gotten HIV. Then the health department called, so I went to get tested. [After the diagnosis], I retreated. I'd never had to deal with anything like that before, and honestly, at the time, Metro Health, the city's health team, was not very helpful. I didn't do anything about the diagnosis for three years, didn't tell any family or friends, didn't seek treatment. I didn't even know there was AARC or the San Antonio AIDS Foundation or anybody else. I tried to forget about it, but I couldn't. I was scared.
Finally, I told my family, which was supportive. Then I met my current wife and told her before we started dating. She said, "Look, you have to get on treatment if we're gonna be safe." But before I was 100% undetectable, my wife, Janeli, became positive, which was also devastating; we were already married at that point. But I went to my primary care provider, who referred me to San Antonio Infectious Diseases Consultants, and Dr. Richard Fetchick there has been my doctor ever since.
Since then, my wife and I have had three kids, who are all HIV negative. HIV doesn't really affect us now on a day-to-day level other than the pill we have to take every night. We spend a lot of time educating people and talking to them about life with HIV today.
TM: What is your job like?
JC: As a medical case manager, I work with clients who've had trouble staying on treatment, keeping them up to date with their doctor appointments and helping them through barriers around housing or food security. The biggest challenge is working with clients who are homeless and/or using drugs. They may want to come in and seek treatment, but when they're using, they forget to take their meds and throw self-care off to the wayside. So I don't say, "Stop using." I say, "Let's try to use less." I try to get them into free substance-counseling programs here in town so they can then focus on their well-being and health.
TM: Tell us a story.
JC: Recently, a client came to me with an eviction notice. Her car, which she and her husband needed to get to work, had broken down, and they had to get it fixed and get a rental, so they couldn't pay their rent. So we hooked her up with funds from our housing department to cover her missed payments so she wouldn't get kicked out.
I also had a client between jobs who was off his treatment. He reached out to me, so we brought him in and reconnected him to care. He had no insurance at the moment, so we connected him to patient assistance programs. Finally, the insurance at his new job kicked in, but he still uses our health clinic.
TM: What do you like most about your job?
JC: Being able to talk directly to people and help them.
TM: Do you share your own HIV status with them?
JC: If they see it in the paper, that's one thing, but I don't tell every client that comes in, no. There was one time with a client who didn't want to take his meds, so I shared my own status to explain why it was important to do so.