Clinica Bienestar Philadelphia FIGHT and Prevention Point Philadelphia Laura Bamford, Miguel Munoz-Laboy, Andres Freire, Ana Rose, and Jose Benitez

Project overview:  Philadelphia FIGHT and Prevention Point Philadelphia (PPP) propose to establish and evaluate a culturally and linguistically competent clinical collaboration called Clinica Bienestar serving HIV positive Puerto Rican IDUs  Located at PPP, a syringe exchange program within the zip code in Philadelphia with the highest concentration of both Puerto Ricans and HIV positive individuals  Philadelphia has the second largest Puerto Rican population in the continental United States after New York City  Puerto Ricans comprise 65% of the Latino population in Philadelphia  The CDC’s National Behavior Surveillance System study demonstrated that Latino IDUs possess the highest HIV prevalence rate (12%) of all racial/ethnic groups  Among Latinos living with HIV/AIDS in Philadelphia in 2011, 37.1% reported IDU as their HIV transmission risk factor compared to only 20.5% of non-Hispanic whites and 25.2% of African Americans

Project overview:  Philadelphia FIGHT is a comprehensive AIDS service organization providing quality and culturally competent HIV primary care, consumer education, advocacy, social services, outreach to individuals living with and at risk for HIV, and access to clinical research and clinical trials  Prevention Point Philadelphia is a syringe exchange program that has served the Puerto Rican community in Philadelphia for over 20 years. PPP also provides HIV and HCV testing, operates the Street Side Health Project, and offers a suboxone treatment program  Clinica Bienestar aims to provide HIV primary care to IDUs within a well established and trusted syringe exchange program

Objectives:  1. Identify HIV positive persons of Puerto Rican origin who are unaware of their status or not engaged in HIV primary care  2. Engage and retain these individuals in a culturally and linguistically competent, scalable, and sustainable model of integrated care  3. Provide quality HIV primary care and HIV/HCV co- infection treatment  4. Successfully address contextual, cultural, and language barriers that impede engagement and retention in care  5. Evaluate this model locally and in collaboration with the national SPNS initiative

Partners and collaborators:  Laura Bamford, MD, MSCE - Principal Investigator/Program Director  Miguel Munoz-Laboy, DrPH - Supervisor of local evaluation  Andres Freire, BA - Project Coordinator  Ana Rose, MSW - Project Coordinator  Jose Benitez, MSW - Executive Director of Prevention Point Philadelphia  Sam Sitron, BA - medical case manager  Nidia Flores - care navigator/outreach coordinator  Norris Square Civic Association, Juaniata Community Mental Health Clinic, Hispanic Clergy of Philadelphia, COMHAR, Congreso, New Journeys in Recovery, St. Christopher’s Hospital for Children, Gay and Lesbian Latino AIDS Education Initiative (GALAEI), Women’s Community Revitalization Project

Intervention description:   Service delivery setting - Prevention Point Philadelphia Priority population - Puerto Rican injection drug users Services and activities - HIV testing, primary HIV medical care, HIV/HCV co-infection treatment, medical case management, care navigation, transportation, culturally and linguistically appropriate education and advocacy initiatives, nutrition services, pharmacy services Staffing – program director/medical director, project coordinators, medical case manager, care navigator, and fellows, residents, and medical students from local university hospitals Recruitment strategies – inform the community of the existence of Clinica Bienestar, identify HIV positive individuals though HIV testing at Prevention Point and outreach sites

Intervention description: Enrollment and linkage to care strategy – same day linkage of newly identified HIV positive individuals to medical case manager and care navigator/outreach coordinator at Clinica Bienestar Retention strategy - provide quality and culturally/linguistically competent medical care in the community in which the patients’ reside, care navigator services, transportation, culturally and linguistically appropriate education initiatives Client incentives - no monetary incentives, clients can receive mail delivery at Prevention Point, collocated syringe exchange and suboxone treatment programs

Local evaluation:  The overall goal of the local evaluation is to examine the effectiveness and potential sustainability of the intervention in improving timely entry, engagement, and retention in quality HIV primary care  IRB protocol will be prepared by Miguel Munoz-Laboy in collaboration with Laura Bamford  Protocol will be submitted to Philadelphia FIGHT IRB Methods to be used include: Pre-post quantitative evaluation at baseline, and at 6, 12, 18, and 24 months Sustainability qualitative process evaluation The above (and below) will be modified as to not duplicate multi-site evaluation

Local evaluation:  Desired study participants: HIV positive Puerto Rican IDUs > 18 years of age No additional incentives to participate in evaluation assessments Evaluation tools will be administered as part of Clinica Bienestar  Data collection instruments and strategies: Behavioral and health outcome variables and measures: 1) viral load at baseline, 6, 12, 18, and 24 months; 2) level of ART adherence at baseline, 6, 12, 18, and 24 months based on self- report scale and HIV viral load 3) proportion of patients on ART more than 12 months with an undetectable HIV viral load Utilization outcome variables and measures: 1) time from identification to initial clinic visit; 2) proportion of patients retained in care (two or more visits in 12 months at least 3 months apart). The above measures will be obtained from medical records.

Local evaluation:  Mediating variables, measures and data collection: personal background, contextual-access factors and attitudinal health-seeking factors  Process Evaluation Methods: Interviews with stakeholders: We will conduct open-ended interviews with four groups: a) program participants (at 6 months, 12 months and after completing their participation in the intervention); b) former participants who ended their participation prior to 12 months; c) implementers of the intervention; d) program champions at local government and AIDS service organizations (individuals not involved in the implementation of the intervention but supporters of it)  Data analysis approaches: Structural equation models (SEM); cost-effectiveness basic analyses; Case studies (Yin, 2009)  Dissemination of key findings - three products for three distinct groups: Summary of findings report Providers’ guide for HIV primary care providers Strategic plan for leaders of community-based health and social service agencies

Project timeline: Start up activities - piloting of program Initiation of demonstration project – we are ready to get started Evaluation planning and implementation – after IRB approval from Philadelphia FIGHT Any key programmatic milestones - enrollment of 6 individuals to date into HIV primary care at Clinica Bienestar who were not previously linked or retained in care

End  Laura Bamford -  Miguel Munoz-Laboy -  Andres Freire -  Ana Rose –  Jose Benitez -