An oasis. A beacon of hope. A safe space. Just a few phrases that describe what Christie's Place is for hundreds of women living with HIV in San Diego, CA. Serving the San Diego community since 1996, Christie's Place is a small nonprofit health and human service agency that has been recognized as a national leader in delivering gender-responsive services through innovative models of care in a region where most HIV-specific resources are targeted to HIV-positive men. With a staff of 21 and significant volunteer support, Christie's Place provides a safety net to address the complex and unique challenges faced by women, children and families impacted by HIV/AIDS, which often keep them from seeking care and/or staying in care. These challenges include extreme poverty, inadequate access to medical care, homelessness or sub-standard housing, mental health conditions, substance abuse, stigma, isolation, discrimination, limited education, language barriers, violence and trauma. Clients have access to a substantial range of services provided by expert staff and a network of collaborative partners who are dedicated to strengthening the health and resilience of women and children affected by HIV. These services include an early intervention services center with resource coordination and referral services; medical case management; mental health services; bilingual childcare; peer navigation; outreach; and basic needs assistance.
Despite these efforts, in 2010 a local unmet need estimate found that 69% of women living with HIV in San Diego County who knew their status were not accessing medical care. These women were facing competing survival priorities that kept them out of care and were at risk for delayed diagnosis, increased morbidity, inadequate HIV management and greater health issues. This was an alarming public health crisis that called for significant attention, innovative solutions and much needed system-level strategies. Put simply, the San Diego system of care was failing the vast majority of women living with HIV in our community. Determined to change this system, Christie's Place applied for and was awarded grants given to communities across the country by AIDS United to support its Access to Care (A2C) initiative. And this is how CHANGE for Women was born.
CHANGE for Women addresses the structural, provider and individual level barriers that women of color living with HIV face which fuel gender-related health disparities. Over the past four years, this highly successful program has significantly impacted the local San Diego County health care engagement cascade by identifying and linking over two hundred women to medical care resulting in a 12 percent decrease in unmet need. Through CHANGE for Women, Christie's Place has developed a partnership of San Diego organizations that serve as a network of care tasked with improving the local care engagement cascade for women living with HIV in our region. CHANGE for Women improves the utilization of medical care and treatment and strengthens the health care and social services systems by:
- ensuring women living with HIV return to care through a peer-led mobile/home-based model and a social marketing campaign;
- improving coordination and communication among health care providers and social support services;
- enhancing linkage to care for women living with HIV through expanded support assistance and utilization of health-information technology;
- supporting health care system change through the development of a Center of Excellence in Women's HIV Care;
- coordinating linkages with immigrant rights/social justice organizations to provide education and assistance; and
- providing legal representation for immigration relief to women living with HIV and legal advocacy for treatment for locally detained clients.
Lessons learned from the first two years of CHANGE for Women confirmed that the program's strategies are effective in identifying women who are newly diagnosed, not in care, and women who are at-risk for falling out of care and linking these women to care. However, we also learned that in order to improve health outcomes we needed to expand our focus from linkage and access to more fully address barriers that women living with HIV experience in retaining care. Women living with HIV experience trauma and Post Traumatic Stress Disorder (PTSD) at a disproportionate rate when compared to the general population of women. Because trauma and PTSD predict poorer HIV-related health outcomes such as inferior health-related quality of life, lower rates of ART adherence and higher mortality rates, CHANGE for Women expanded its programmatic focus to explicitly address the effects of interpersonal violence and victimization on a woman's lived experiences. Made possible by the support of AIDS United and MAC AIDS Fund, in 2013 CHANGE for Women launched Phase II Retention in Care (RiC), a trauma-informed and gender-responsive bio/psycho/social model that aims to comprehensively and systematically address trauma-related barriers to retention in HIV care faced by women of color living with HIV in San Diego.
CHANGE for Women Phase II RiC endeavors not only to improve retention in care but also works to bring attention to the intersections of gender, violence and HIV play out in the lives of women living with HIV and implementing practices and strategies aimed at individual, relational and community healing, resiliency and wellness. Perhaps the early impact of the programmatic expansion is best illustrated by a case example. Sarah was first connected to the CHANGE for Women program in 2012 and began working with her RiC Peer Navigator in 2013. Upon their first meeting, Sarah's Peer Navigator was concerned that Sarah was extremely isolated, had poor self-esteem and was not consistently adhering to her HIV medication regimen. Further, Sarah was in an abusive relationship and because violence had been such a frequent occurrence in her life, she was unaware of how dangerous the situation had become. Sarah also had many concerns related to food insecurity and lack of reliable transportation to her medical visits. Through RiC, Sarah has engaged regularly with her Peer Navigator and also accessed medical case management and behavioral health services. With her CHANGE for Women RiC treatment team's support, she has demonstrated tremendous growth in a very short period of time. Through therapy and one-on-one support from her Peer Navigator, she has changed her outlook on her abusive relationship and has filed for a divorce.
Additionally, with the help of her Case Manager, she is gaining access to housing, food and transportation resources which are helping her to become more and more independent. She has also become very active in our local HIV community by volunteering at local agencies including Christie's Place and joining HIV planning and advocacy groups. She is consistently adherent to her medications and has an undetectable viral load. Additionally, through her participation in support groups, she has become an inspiration to many women with her perseverance and positive encouragement. We are very proud of how far Sarah has come, but more importantly she is proud of the positive steps that she has taken.
Support from AIDS United and MAC AIDS Fund has been the impetus for perhaps one of the most significant shifts in our agency's history; our organizational commitment to trauma-informed care. Through ongoing dialogue and training, the principles and practices of trauma-informed service provision have been embraced by all Christie's Place staff and management. When asked how the shift to trauma-informed service provision has impacted their work at Christie's Place, perspectives on trauma and ideas about professional identity, staff provided the following sentiments:
Shifting into trauma-informed service provision initially seemed like it would be a seamless process. It has turned out to be an eye opening experience. At the beginning a lot of what I learned initially seemed like a combination of common sense and good customer service. I have come to understand that being trauma-informed is so much more. It's an everyday process that allows us to relate to others in more healing ways. Being trauma-informed has pretty much impacted every aspect of my life -- professional and personal.
-- Edna Burgos, medical case manager
Trauma-informed service provision has helped me to have a more complex understanding of the relational healing that occurs for both provider and client within the context of mutuality. This concept is vital in providing compassionate care to populations often affected by multiple layers of historical, community and personal traumas.
-- Sara Duran, CHANGE for Women care coordinator
Since its inception, CHANGE for Women has served as a catalyst for systemic change of the HIV care delivery system in San Diego. The program has been recognized for its valuable contributions in San Diego County and has served as a model for gender-responsive care for women living with HIV throughout the United States. What began as a response to an alarming public health crisis has evolved into a charge to CHANGE the way that we view service delivery for women living with HIV. As an organization whose mission is dedicated to providing services to women impacted by HIV/AIDS situated in a framework that incorporates health equity and social justice, Christie's Place is pioneering a model that truly addresses healing a lifetime of hurt.
Erin Falvey is clinical manager at Christie's Place.