Needs Assessment: Summary/Findings The state of Texas currently holds the highest rate of uninsured residents in the US and among Texas residents; one in four adults do not have health insurance of any form.6 It is not surprising, then, that the 2009 needs assessment revealed 29% of participants who responded did not have insurance of any kind. Compounding this is the fact that health insurance is a complex need to meet; the need could apply to a client who currently has insurance and requires assistance with premiums, office visit and medication co-pays or deductibles; or if the client is eligible for, but does not have currently have, insurance coverage and requires assistance with purchasing a policy.
Participant confusion about the allowable services in the Emergency Financial Assistance and Outreach categories led to these services being rated as high need in the 2006 survey. This informed a redesign of the survey tool, which prompted the data collector to explain each service category before asking participants about that specific service. Given a better explanation of the true nature of these services, the need for Emergency Financial Assistance dropped from first place to sixth. However, it is still uncertain what client needs are present that participants felt required Emergency Financial Assistance. It is also unclear whether these needs may already be met under the funded service categories in each HSDA. Future needs assessments will investigate this issue in greater detail. Outreach seemed to move up to 15th from 18th, though there were only 15 service categories investigated in the 2009 survey as compared to 30 in the 2006 survey.
Substance abuse continues to be an issue in the CTHASA, with nearly half of survey participants reporting a history of using street drugs, and nine percent reporting current use. Though none of the survey participants reported currently injecting drugs, 21% reported a history of intravenous drug use. The actual percentage of participants who use or have a history of using street and intravenous drugs may be higher given the legal issues and stigma surrounding substance use and abuse. Four percent of all participants stated that using drugs or drinking alcohol affects their ability to manage their HIV infection.
Of those reporting current drug or alcohol use, two-thirds stated they were not interested in receiving treatment. However, 14% of participants with current drug or alcohol use reported that they would be interested in a treatment program that catered exclusively to PLWHA. Thirteen percent of respondents indicated they would like more information about what services are available and where to go for treatment; 7% stated they would like access to a residential substance abuse program; 3% expressed a need for immediate access to a treatment program when they are ready; 3% indicated free treatment is needed; and 3% need transportation to treatment. Totals do not come to 100% as survey participants were given the option to select multiple options when indicating the form of treatment or information they would like to receive.
The Mental Health Services category (referred to as Counseling in the survey) ranked 11th across all HSDAs. Nearly half (47%) of the participants surveyed reported being diagnosed with a mental health condition at some point in their lives. Among participants who had received a formal diagnosis, 38% were diagnosed with depression, 21% were diagnosed with anxiety, and 12% were diagnosed with bipolar disorder. Though several clients had received formal diagnoses of mental health conditions at some point, a greater number reported that they were currently experiencing mental health conditions at the time of the survey (56%). Of these participants, 40% reported currently experiencing depression, 31% were experiencing anxiety, and 14% were experiencing bipolar disorder. Given the high percentage of PLWHA living with mental health conditions in the CTHASA, it is not surprising that antidepressants are the second most common medication reported among participants at 36%.
One success that became apparent in the course of the survey was the proportion of clients currently adhering to their antiretroviral therapy and highly active antiretroviral therapy (ART/HAART) regimens. Eighty-six percent of survey participants reported taking an ART/HAART treatment regimen. Of these participants, 72% reported not missing a dose in the last week. Twenty-one percent of participants reported missing between one and three doses in the past week, and only 7% reported missing a dose four or more doses in the previous week. When asked why they missed a dose, or did not take their medication as prescribed, 32% of participants responded that they forgot to take their medication. This was by far the most common answer, with “other” the second most often stated answer (21%), and “side effects” being the third (8%). This presents an opportunity for case managers to work more closely with CTHASA clients to develop effective habits and strategies for remembering to take medications.
Special Population: Recently released/previously incarcerated Linkage to care can present a difficult challenge for previously incarcerated PLWHA. Twenty eight survey participants (12%) reported having been incarcerated at some point in the 12 months before the survey was conducted, with all participants reporting that they were diagnosed with HIV before incarceration. Seventy-eight percent stated that jail/prison staff were aware of their HIV status, with the same individuals reporting receiving medical care for their HIV while incarcerated. Twenty-two percent of individuals reported jail/prison staff as being unaware of their HIV status, though these individuals were incarcerated for short periods in county jails.
When asked about information and services provided to them upon release, 44% of previously incarcerated participants stated they were given a supply of HIV medication to take with them when released, 22 percent were given information about finding housing, and another 22 percent were given a referral to medical care.7 It is notable that 56% of those released from prison in the past year were not provided any referrals to care upon release from jail or prison. When asked what barriers to accessing HIV services they experienced after release, more than a third (38%) stated they did not have any difficulty accessing care. An additional 38% reported financial struggles or lack of insurance as a barrier to getting HIV services upon release, and 13% reported “other” reasons, which including being referred to the wrong county for services.
It is discouraging that more than half of the individuals released from prison or jail in the last 12 months did not receive any type of link to care. Though this only amounts to about 7 individuals, these are 7 individuals who were at increased risk of never linking to care post-release. As the individuals surveyed were sampled from a list of clients who had received services within the past 12 months, it is likely that the actual proportion of PLWHA who never link to care or are delayed in linking to care after release is higher. This prompted BVCOG to adopt increasing linkages to care for recently released PLWHA as a Phase II objective in 2010. When the Texas Department of Criminal Justice (TDCJ) and DSHS began partnering in 2011 to create a coordinated statewide program for increasing linkage to care for recently released PLWHA, BVCOG efforts shifted to focus on establishing relationships with city and county level law enforcement agencies.
Special Population: Pregnant PLWHA Of the 46% of survey participants who identified as female, only 3% stated that they were either currently pregnant, or had been pregnant within the past 12 months. Though the actual number of pregnant or recently pregnant PLWHA is relatively low and does not allow for statistically significant conclusions, it is encouraging that three-quarters of pregnant or recently pregnant PLWHA indicated that they had received or were currently taking medication to prevent perinatal transmission.
Needs Assessment: Service Category Rankings and Explanation The following table presents the results of the service category importance ranking from the analysis conducted by the CCHD. The survey instrument utilized asked participants to rate then rank, in order of importance, the 15 HRSA defined service categories explored in the survey. The service ranked as first was listed most often as the most important service, and so on. The six services in bold are part of the twelve HRSA-defined core medical service categories.
Percent of respondents reporting current/ past use of this service
Percent of those with no history of use, but stating a need for, the service