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Chapter 7: Priority Population Descriptions and Prioritized Interventions

This chapter includes many of the significant changes made to the CPG Comprehensive HIV Prevention Plan since it’s last Update in 1997.   Most importantly, this chapter includes CPG recommendations about the types and priority of interventions to be funded by the Bureau of Health for each priority population.  These recommendations are found within each of the population sections along with revised population descriptions, prioritized needs, and HIV prevention linkages.

Before presenting population descriptions and prioritized interventions, the process used by the CPG for prioritizing needs and interventions, including use of behavioral science and incorporation of Needs Assessment information, is described.

7.1       Prioritizing Interventions

The process of prioritizing interventions, like all other changes to the population sections described in this chapter, were accomplished by the Population Committees.  Population Committees exist for each priority population, and all CPG members sit on the one Population Committee which corresponds most closely to their personal background and experience.  Population Committees vary in size from two to six members.

Prioritization was guided by trainings provided by the Training and Technical Assistance Committee.  Training and evaluation materials distributed during the prioritization process are included here in Appendices 4 and 5.

7.1.1   Step One:  Determining and Prioritizing Needs

The first step in the process of prioritizing interventions was to determine population-specific needs within each Population Committee.  Needs were formulated by looking at previous versions of the Plan, through the personal experience of committee members, and by examining newly acquired CPG Needs Assessment data.  In this way, all of the Population Committees determined a list of important, HIV prevention-related needs. Five of the six Population Committees then ranked their list of needs through the use of a variety of different methods, depending on the size of the committee.

7.1.2   Step Two: Gap Analysis

Next, Population Committees conducted a "gap analysis," to see if  HIV-prevention needs are being met by existing services and interventions.  Because not all Needs Assessment data pertaining to HIV prevention and care services had been analyzed, the Bureau of Health provided supplemental data about HIV prevention interventions currently in place.  Sources of data provided for the Gap Analysis included the following:

• Evaluation Summary of 1998 Interventions, Bureau of Health (BOH)

• 8 Interventions/Demographic Summary, BOH (list of the numbers of high-risk people reached by BOH interventions during 1998 and their basic demographic characteristics)

• Maine Community AIDS Partnership (MCAP) Interventions

• Department of Education (DOE) Interventions

• American Red Cross (ARC) Interventions

• Office of Substance Abuse (OSA) Interventions

• Population Committees took into account which needs were met or unmet by available services when considering the priority of specific interventions.

7.1.3   Step Three:  Prioritizing Interventions

The final step of the process for each Population Committee involved prioritizing interventions for their given, at-risk population.  This process took into account both current behavioral science theory about the effectiveness of interventions, and whether or not HIV-prevention needs are being met.  Members tried to answer four basic questions:

• What interventions could be directed at meeting the needs of each priority population?

• What interventions are currently being done to meet the needs of each priority population?

• What is the difference between what is currently being done and the priority interventions you want to be doing?

• How can statewide HIV prevention shift towards the priority interventions we want to happen?

Using the above questions and considering current knowledge about what types of interventions are most effective in reducing risk for HIV transmission, each Population Committee prioritized interventions.  As with needs, prioritization methods were not uniform across all committees.   All committees reached consensus about priority interventions for their at-risk population.

7.2       Population Descriptions, Needs, Interventions and Linkages

The population sub-sections listed below are divided into six parts that describe each population and list HIV prevention needs, CPG recommendations for HIV prevention interventions, and linkages for prevention activities.  Specifically, the content of each sub-section includes:

•  Description of the population

• Epidemiological Characteristics

• Behavioral Characteristics

• Demographic Characteristics

• Behavioral/Demographic Characteristics

•  Identified needs

• Prioritized Interventions

• Linkages to relevant information and to primary and secondary prevention.

Sub-sections for each of the six prioritized populations are presented below.

7.2.1   Males Who Have Sex with Male

Population Description:

The noun male rather than the noun men is used in the definition of males who have sex with males to be inclusive of young males.  The definition refers to the sexual behaviors of males, not to how they are identified.  The following description, not exhaustive, includes epidemiologic, behavioral and demographic characteristics of males who have sex with males at highest risk of HIV infection, re-infection or transmission.  Information pertinent to males who have sex with males may also be found in the Population Sections "Youth at Risk," "People of Color at Risk," "Injecting Drug Users," and "Populations with Special Needs."

Epidemiological Characteristics

Males who have sex with males represent the largest proportion of cumulative AIDS cases in Maine with 68% of all cases diagnosed since 1994.  The following graphic shows the percent of Maine AIDS cases attributed to of males who have sex with males (MSM) and those with dual male to male sex/injecting drug use (IDU) risk during recent years and cumulatively.

Region of Residence at Diagnosis:  More than half of all AIDS cases attributed to males who have sex with males occurred among those living in York and Cumberland Counties at the time of their diagnosis (57%).  Another 28% of cases resided in Central Maine (Androscoggin, Franklin, Kennebec, Knox, Lincoln, Oxford, Sagadahoc, Somerset, and Waldo Counties) and 14% in Northern Maine (Aroostook, Hancock, Penobscot, Piscataquis and Washington Counties).

Age at Diagnosis:  Eighteen percent of reported AIDS diagnoses among males who have sex with males occurred in individuals under 30 years of age, meaning that many males who have sex with males were infected in their teens or early 20's.  The following graph shows age group at time of diagnosis for Maine AIDS cases attributed to males who have sex with males risk.

Despite concerted grass-roots efforts both nationally and locally, males who have sex with males in Maine continue to be at highest risk when compared to all other HIV transmission risk groups.  A recent statewide study of males who have sex with males found that 34% of respondents in non-monogamous relationships and 41% of HIV-positive respondents engaged in unprotected receptive anal intercourse in the preceding 12 months. The same study indicated that respondents had higher rates of alcohol, drug and cigarette use than the general population.

In addition, anecdotal information in Maine correlates with national research findings that males who have sex with males who do not self-identify as gay or bisexual may be at higher risk for HIV than other males who have sex with males for many reasons, including the fact that males who have sex with males may not have access to HIV prevention-related information or peer support.

Behavioral Characteristics

Certain behaviors may increase the level of risk for males who have sex with males, including:

• Males with multiple sex partners

• Sex workers / males who exchange sex for goods and/or services

• Males who use alcohol and other drugs

• Males who inject drugs and/or share needles

• Males with addictive, compulsive behaviors

• Male sexual partners of males who engage in any of the above behaviors

• Males with low self-esteem

  Demographic Characteristics

Certain demographic characteristics may increase the level of risk for males who have sex with males, including:

• Males who call themselves or are called homosexual, questioning, bisexual, married, heterosexual, experimenting, transgender, gay or queer.

• Males from ethnic or racial minority groups

• Males who have experienced sexual abuse and/or nonconsensual sex

• Economically disadvantaged males

• Males with mental illnesses

• Males with developmental disabilities

• Deaf males

• Males who are migrant workers

• Males with low educational attainment

  Behavioral / Demographic Characteristics

Certain characteristics termed here as "Behavioral/Demographic" may increase the level of risk for males who have sex with males, including:

• Males who are homeless

• Males who are isolated geographically, socially or emotionally

• Males who are affected by intrapersonal violence

• Detained and incarcerated males

  Needs of Males Who Have Sex with Males

The population Males who have sex with males is not a homogenous population, and encompass a wide range of cultures, individual experience and behavior.  Specific response to primary and secondary prevention needs of HIV+ men and to the psychosocial needs of HIV- men need to be provided.  In addition, needs vary according to age and stage of personal development.

Needs include:

Societal acceptance of males who have sex with males along with physical, emotional, spiritual and mental safety are essential elements of all HIV prevention interventions.  Other needs are prioritized below:

Top Priorities:

•  Access to HIV counseling and testing, including anonymous counseling and testing

• Skills that facilitate behaviors that eliminate or reduce the risk of HIV infection, transmission and/or re-infection including harm reduction, condom use, identification and management of triggers that interfere with safer sex and harm reduction practices, and communication/ negotiation skills to implement and maintain these practices

 Moderately Important Priorities:

• Knowledge of personal HIV status

•  Increased belief in ability to change personal behavior

• Access to health care and social services that are culturally competent and knowledgeable about HIV

• Knowledge of primary HIV-related resources

• Social connections and support networks, including non-bar & non-sex environments

• Increased awareness of personal risk for HIV transmission and/or re-infection and ability to identify risk behaviors and develop personal interventions

Lower Priorities at this time:

• Knowledge of accurate HIV transmission information

• Availability of condoms, lube and safer sex products

• Easy access to condoms, lube, and safer sex products

• Knowledge about transmission, prevention and treatment of STDs other than HIV

Prioritized Interventions for Males Who Have Sex with Males 

• 1. Provide Outreach: go where the at-risk people are.

• a) Provide Counseling and Testing through expansion to community and alternative settings. Focus on culturally competent marketing to access the target population.

• 2. Provide group-level interventions both peer and non-peer led.

• 3. Provide individual-level interventions, both peer and non-peer led.

• a) Provide Counseling and Testing at established anonymous and confidential sites.

• 4. Develop community building efforts for members of the prioritized population.

• 5. Provide community (geographic) level interventions and mobilizations in order to modify community norms, values and practices through social marketing, diffusion and community building.  Interventions should:

• a)  Correct myths and misconceptions about HIV/AIDS.

• b)  Encourage peer networking and social supports.

• 6. Develop and market public information services, including hotlines, chat rooms, etc.

• 7. Advocate for, develop and implement alternative sentencing programs for non-violent crimes which involve high-risk behaviors.

Linkages

The following list identifies a variety of ways in which information about, or relevant to, the prioritized Males Who Have Sex With Males population in the state of Maine is connected to the Community Planning process and accessible to Community Based Organizations:

•  Epidemiologic Surveillance: The HIV/AIDS Surveillance Coordinator for the State of Maine, Mark Griswold, is the Public Health Co-Chair of the CPG.  He compiles data specific to this population and provides to both the CPG and Community Based Organizations as requested. 

• Behavioral Surveillance: Counseling and Testing data and STD data informs the CPG.

• Needs Assessment Data:  Needs assessment information is available concerning the HIV prevention needs of males who have sex with males.

• Research used by the CPG and community-based organizations includes published research on males who have sex with males’ HIV prevention needs and effective interventions, two focus groups with this population, and materials provided by national HIV prevention organizations and the Centers for Disease Control and Prevention.  Refer to Ways to Access Behavioral Science Information and Models found in Chapter 4.

• In addition to the above, CPG members provide elements of all of the above, providing linkages to AIDS service organizations and community-based organizations, personal contacts, professional knowledge, personal experience, and the like.

Linkages between Primary and Secondary Prevention

Primary and secondary prevention for males who have sex with males are linked most directly within the five AIDS service organizations which provide both HIV prevention and case management services.  These organizations include:

• The AIDS Project (TAP) in Portland, located in the southern section of the state and providing services to Androscoggin, Cumberland, Oxford, and York Counties

• Down East AIDS Network (DEAN), located in Ellsworth, and serving Washington and Hancock Counties.

• Eastern Maine AIDS Network (EMAN),  located in Bangor and serving Aroostook, Penobscot and Piscataquis Counties.

• Coastal AIDS Network (CAN - formerly Waldo-Knows AIDS Coalition) located in Belfast, serving Waldo and Knox Counties with case management, and prevention services to Waldo, Knox and Lincoln Counties.

• Dayspring AIDS Support Services, located in Augusta, provides case management and HIV prevention services to Kennebec, Somerset, Sagadahoc, and Franklin Counties.

 Additionally, all Counseling, Testing and Partner Notification and STD Clinic services provide direct linkages with resource and referral options for both HIV- and HIV+ individuals.

7.2.2   Women at Risk

Population Description:

Woman at Risk refers to females over the age of 24 who exhibit high-risk behaviors, or who are in situations which place them at higher risk for HIV infection.  Females at risk who are 24 years of age and under are also described in the population description "Youth at Risk."  In addition, women are described in population sections for "Injecting Drug Users," "People of Color," and "Populations with Special Needs."  The following lists, not exhaustive, includes epidemiologic, behavioral and demographic characteristics of women at risk at highest risk of HIV infection.

Epidemiological Characteristics

Since the beginning of the epidemic, 91 women in Maine have been diagnosed with AIDS, comprising 11% of  total cases.  While only one case of AIDS in a woman had been reported prior to 1988, 21% of 1998 cases were female.  The chart below shows the percent of AIDS cases attributed to women, by year, since 1994.

Region of Residence at Diagnosis:  Forty-three percent of women diagnosed with AIDS in Maine resided in either York or Cumberland Counties.  Another 32% lived in Central Maine (Androscoggin, Franklin, Kennebec, Knox, Lincoln, Oxford, Sagadahoc, Somerset and Waldo Counties) and 25% lived in Northern Maine (Aroostook, Hancock, Penobscot, Piscataquis and Washington Counties).  The majority of Maine women with AIDS live outside of metropolitan areas.

Age at Diagnosis:  Thirty-one percent of women diagnosed with AIDS in Maine were under 30 years old, meaning that many women could have been infected with HIV in their teens or early twenties.  Thirteen percent of women were 24 years of age or under when they received their AIDS diagnosis.  The following chart shows age groups of women with AIDS in Maine at the time of their diagnosis:

Transmission Risk:  Thirty-two percent of women reported with AIDS were exposed to HIV through injecting drug use.  Forty-six percent of women reported with AIDS had heterosexual HIV exposure, in most cases to a male with an IV drug history.  Another 4% contracted HIV through blood transfusions and 3% were infants born to infected mothers.  Risk was not know for 14% of women receiving AIDS diagnoses.

Behavioral Characteristics:

Certain behaviors may increase the level of risk for women at risk, including:

• Women who have multiple sex partners
• Women who have sex with injecting drug users
• Women who share drug injecting equipment
• Women who use/abuse alcohol and/or other drugs
• Women who trade sex for money, drugs, etc.

 Demographic Characteristics:

Certain demographic characteristics may increase the level of risk for women at risk, including:

•  Women who have a history of sexually transmitted diseases

• Women who are currently infected with a sexually transmitted disease

• Women who have experienced childhood abuse (which may be emotional, physical, incestual or sexual)

• Women who have a history of mental illness

• Women who are developmentally delayed

• Women who are physically disabled

• Women are educationally deprived

• Women who are economically disadvantaged

 Behavioral / Demographic Characteristics:

Certain characteristics, termed here as "Behavioral/Demographic" may increase the level of risk for women at risk, including:

• Women who are isolated either geographically, socially, emotionally

• Women who homeless

• Women who are incarcerated

• Bisexual women who engage in high risk behaviors

• Women who have sex with women and engage in other high risk behaviors

• Women who have a history of intrapersonal violence

• Women who have low self-esteem

• Women who experience gender-related power-imbalances (which may be physical, emotional, or financial)

Needs for Women at Risk:

 The following needs are not listed in rank order:

• Availability of condoms, lube and safer sex products

• Easy access to condoms, lube, and safer sex products

• Physical, Emotional, Spiritual, Mental Safety

• Knowledge of accurate HIV transmission information

• Development of skills to ensure correct condom use and other safer sex practices

•  Identification and management of sexual triggers that interfere with safer sex / harm reduction practices.

• Development of negotiation and communication skills

• Personal risk awareness

• Increased sense of self efficacy for belief in behavior change

• Access to health care and social services

• Access to HIV Counseling & Testing, including anonymous counseling & testing

• Development of social connections and support networks

• Knowledge of accurate STD transmission including information about how infection with an STD increases the risk for HIV transmission

 Prioritized Interventions for Women at Risk

• 1. Outreach focused upon women at risk

• 2. Individual-level interventions that are both peer and non-peer led which:

• address barriers to HIV prevention experienced by women;

•  provide skills-building around behaviors including condom use and other safer sex practices;

• provide relationship and communication skills-building.

• 3. Group-level counseling that is both peer and non-peer lead which:

• addresses barriers to HIV prevention experienced by women;

• provides skills-building around behaviors including condom use and other safer sex practices;

• provides relationship and communication skills-building.

• 4. Find or build community-based organizations or AIDS service organizations which provide women-specific programs.

• 5. Educate institution-based providers regarding the HIV prevention needs for women.  Institution-based providers may include:  schools, state departments and agencies, shelters, medical providers, substance abuse treatment services, etc.

• 6. Provide counseling and testing through expansion to community settings and alternative sites and anonymous and confidential sites.

• 7. Advocate for, develop and implement alternative sentencing programs for non-violent crimes which involve high-risk behaviors, including drug-related crimes and crimes related to the sex industry.

Linkages

The following list identifies a variety of ways in which information about, or relevant to, the prioritized Women at Risk population in the state of Maine is connected to the Community Planning process and accessible to Community Based Organizations:

• Epidemiologic Surveillance: The HIV/AIDS Surveillance Coordinator for the State of Maine, Mark Griswold, is the Public Health Co-Chair of the CPG.  He compiles data specific to this population and provides to both the CPG and Community Based Organizations as requested. 

• Behavioral Surveillance: Counseling and Testing data and STD data informs the CPG.

• Needs Assessment Data:  Needs assessment is available concerning the HIV prevention needs of women at risk.

• Behavioral Surveillance specific to HIV risk factors and this population in Maine is currently unavailable.  Data is collected by the Bureau of Health on sexually transmitted disease and pregnancy, but this data is insufficient for our use.  This surrogate data, while helpful, leaves unanswered questions.

• Research used by the CPG and community-based organizations includes published research on women's HIV prevention needs and effective interventions, one focus group with HIV+ women, and materials provided by national HIV prevention organizations and the Centers for Disease Control and Prevention.

• In addition to the above, CPG members provide elements of all of the above, providing linkages to AIDS service organizations and community-based organizations, personal contacts, professional knowledge, personal experience, and the like.

 Linkages between Primary and Secondary Prevention

Primary and secondary prevention are linked in two particular ways for women in Maine.  There are two prevention case management projects for women which are each based in sexually transmitted disease clinics, one at the Bangor City Health Department and one at Tri-County Health Services in Auburn.  Portland Public Health Services also are effective in connecting primary and secondary prevention services through their range of service to financially challenged women.  Historically, the most direct link between primary and secondary prevention services was found within the five AIDS service organizations which provide both HIV prevention and case management services.  This link continues to be extensive and important in the State of Maine.  These organizations are:

• The AIDS Project (TAP) in Portland, located in the southern section of the state and providing services to Androscoggin, Cumberland, Oxford, and York Counties

• Down East AIDS Network (DEAN), located in Ellsworth, and serving Washington and Hancock Counties.

• Eastern Maine AIDS Network (EMAN),  located in Bangor and serving Aroostook, Penobscot and Piscataquis Counties.

• Coastal AIDS Network (CAN - formerly Waldo-Knows AIDS Coalition) located in Belfast, serving Waldo and Knox Counties with case management, and prevention services to Waldo, Knox and Lincoln Counties.

• Dayspring AIDS Support Services, located in Augusta, provides case management and HIV prevention services to Kennebec, Somerset, Sagadahoc, and Franklin Counties.

Additionally, all Counseling, Testing and Partner Notification and STD Clinic services provide direct linkages with resource and referral options for both HIV- and HIV+ individuals.

7.2.3   Injecting Drug Users

Population Description:

According to epidemiological data, the number of injecting drug users, or people with histories of injecting drug use with HIV or AIDS, continues to grow.  It appears that due to the higher quality and the lower price of injecting drugs, the availability of these drugs continues to rise along with the number of people using them.  The continued social and political stigmatization of injecting drug users also contributes to the risky behavior of sharing needles, making them at increased risk for HIV.

Injecting drug users cannot be identified by where they live or how much they earn.  However, some identified situations and behaviors put these individuals at increased risk.  Of course, the riskiest behavior for injecting drug users is sharing needles.  It is important to note that the sexual partners and unborn children of injecting drug user's sexual partners are also at increased risk for HIV.

The following description, not exhaustive, includes epidemiologic, behavioral and demographic characteristics of injecting drug users at highest risk of HIV infection, re-infection or transmission.  Since injecting drug users may be any race, gender, age, ethnicity or sexual orientation, and may have other special needs, information pertinent to injecting drug use may be found in each of the five other population sections.

Epidemiological Characteristics

Overall, there has been little data available on the extent and nature of injecting drug use in Maine. Estimates of the number of injecting drug users by the Maine Office of Substance Abuse have ranged from 1,200 to 4,800 persons in recent years.

Of the 840 AIDS cases diagnosed in Maine through December, 1998, 125 (15%) are attributed to syringe sharing during injecting drug use.  Ninety-seven cases (77%) occurred among males and 29 cases (33%) occurred among females.  In addition, we believe through anecdotal reports that a significant number of infections have occurred from sexual contact with those infected through injecting drug use.  The chart below shows the percent of AIDS cases attributed to injecting drug users, by year, since 1994.

Region of Residence at Diagnosis:  Forty-eight percent of injecting drug users diagnosed with AIDS in Maine resided in either York or Cumberland Counties.  Another 37% lived in Central Maine (Androscoggin, Franklin, Kennebec, Knox, Lincoln, Oxford, Sagadahoc, Somerset and Waldo Counties) and 15% lived in Northern Maine (Aroostook, Hancock, Penobscot, Piscataquis and Washington Counties).

Age at Diagnosis:  Seventeen percent of injecting drug users diagnosed with AIDS in Maine were under 30 years old, meaning that many could have been infected with HIV in their teens or early twenties.  The majority of this population were in their thirties when they received an AIDS diagnosis.  The following graph shows age groups of injecting drug users with AIDS in Maine at the time of their diagnosis:

Behavioral Characteristics:

Certain behaviors may increase transmission risk for injecting drug users, including:

•  use and abuse of alcohol, prescription drugs, and other chemicals
• runaway or homeless injecting drug users
• employed or unemployed injecting drug users
• all sexual partners of injecting drug users

Demographic Characteristics:

Injecting drug users may be any race, gender, age, ethnicity or sexual orientation.  Since this population is defined by a behavior, demographic characteristics may have less impact on injecting drug users than on other at-risk groups.  However, some demographics may increase risk for infection, including:

•  racial/ethnic minority injecting drug users

•  Injecting drug users with a mental illness

• youth who inject drugs

It should be noted that all sexual partners of injecting drug users are at increased risk for HIV and homeless injecting drug users may be at highest risk.  Injecting drug users and their sexual partners are also at high risk for hepatitis C & other serious diseases.

Needs for Injecting Drug Users

1. Needs for injecting drug users are listed below in order of priority.

2. HIV prevention education, access to clean needles, and substance abuse treatment and other services.

3. More methadone programs throughout the State of Maine.

4. More needle exchange programs throughout the State of Maine.

5. Raising public awareness to the fact that drug use and abuse exists in Maine and that this impacts directly on the spread of HIV.

6. Increased access to affordable/no cost HIV testing and counseling.

7. Access to treatment using a harm-reduction model.

8. Culturally appropriate services for injecting drug users.

9. Accurate information for youth about drug use and the related danger of HIV infection.

10. Accurate information for women about the risk of HIV infection through injecting drug use and partnering with injecting drug users.

 Prioritized Interventions for Injecting Dug Users:

1. Interventions for injecting drug users are listed below in order of priority.

2. Implement individual-level and group-level outreach programs, staffed by trained, recovering substance abusers, to target injecting drug users with information about HIV infection and risk reduction, needle exchange, counseling and methadone programs.

3. Implement methadone programs more widely across the state.

4. Implement needle exchange programs more widely across the state.

5. Increase the accessibility of anonymous HIV test sites throughout the state.

6. Create more training opportunities for professionals working with substance abusers to explore harm reduction as an effective and viable treatment modality to reduce HIV risk.

7.  Increase opportunities for substance abuse professionals for diversity training that also explores HIV risk reduction.

8. Prevention case management for injecting drug users, including homeless injecting drug users.

Linkages

The following linkages provide some information regarding the connections between and among injecting drug use, risk behaviors, and HIV disease in Maine.

• Epidemiologic Surveillance: The surveillance coordinator of the state of Maine, Mark Griswold, is the Public Health Co-Chair of the CPG.  He compiles data specific to this population and provides same to both the CPG and Community Based Organizations as requested.

• Needs Assessment Data:  Needs assessment is available concerning the HIV prevention needs of injecting drug users.

• Research used by the CPG and community-based organizations includes selected published research on the effectiveness of needle exchange and other interventions; focus groups summaries; presentations by the Portland Public Health IDU Outreach Project staff members and personal accounts from CPG members.

• Portland Public Health and other counseling and testing providers furnish alternative site HIV prevention counseling and testing services.

• In addition to the above, CPG members provide elements of all of the above, providing linkages to community-based organizations, personal contacts, professional knowledge, personal experience, and the like.

Linkages between Primary and Secondary Prevention

Primary and secondary prevention directly addressing Injecting Drug Users are linked together in the southern part of the state.  There are three efforts of note, 1) Outreach by Portland Public Health, 2) Street Outreach by The AIDS Project which is not IDU specific and includes Androscoggin County, and 3) the Methodone treatment centers in South Portland and Winslow.  Portland Public Health provides group sessions to all Methodone recipients, who must attend within 90 days, but may attend as many of the two hour weekly groups as they wish.  Additionally, Portland Public Health provides confidential HIV Counseling and Testing free of charge to these clients.  The Methadone treatment centers also makes referrals to community-based organizations when needed

Additionally, the five AIDS Service Organizations which provide both HIV Prevention and Case Management services statewide are linkages.  These organizations include:

• The AIDS Project (TAP) in Portland, located in the southern section of the state and providing services to Androscoggin, Cumberland, Oxford, and York Counties

• Down East AIDS Network (DEAN), located in Ellsworth, and serving Washington and Hancock Counties.

• Eastern Maine AIDS Network (EMAN),  located in Bangor and serving Aroostook, Penobscot and Piscataquis Counties.

• Coastal AIDS Network (CAN - formerly Waldo-Knows AIDS Coalition) located in Belfast, serving Waldo and Knox Counties with case management, and prevention services to Waldo, Knox and Lincoln Counties.

• Dayspring AIDS Support Services, located in Augusta, provides case management and HIV prevention services to Kennebec, Somerset, Sagadahoc, and Franklin Counties.

Additionally, all Counseling, Testing and Partner Notification and STD Clinic services provide direct linkages with resource and referral options for both HIV- and HIV+ individuals. 

7.2.4   People of Color at Risk

Population Description:

Many People of Color populations are at high risk for HIV infection, not because of their race or ethnicity, but because of the risk behaviors they may engage in.  As with any population, it's not who you are but what you do that puts you at risk for HIV.

People of Color at Risk are defined within this context as: African Americans/Blacks, Hispanics and American Indians.  It is important to acknowledge that this definition does not include all people of color in this state, as there are numerous racial and ethnic minorities including immigrants, migrant workers, and refugees.  Because of their diversity, assessment of the needs of these populations is difficult, and the focus remains on the three larger groups of People of Color:   African American/Blacks, Hispanics, and American Indians.  This focus is not intended to exclude other populations, but is a response to limited resources and to epidemiologic data indicating that these three groups are at greatest risk.

Although there are wide differences in the three populations on which the CPG does focus, there are also some similarities in descriptors which follow:

• Each group is composed of relatively small numbers of members.

• Members of each group are dispersed around the state, with minority population "clusters" found in both urban areas and agricultural regions.  In addition:

• American Indians may live on tribal lands, but the tribes are scattered.

• There is no single African American neighborhood or geographic community location.

• Hispanics may reside in pockets related to employment or sponsorship patterns.

• Rates for infection are disproportionately high in all three populations (see below).

• Cultural differences exist between and among populations

• All three populations may be affected by increased rates of substance abuse.

 The more detailed description of each of the three populations below was developed by the People of Color members of the CPG with assistance from other committee members.  This includes epidemiologic, demographic and behavioral characteristics which may increases HIV risk for People of Color. Since people of color may be any age, gender, or sexual orientation, and may have a variety of special needs, information pertinent to people of color may be found in each of the five other population sections.

Epidemiological Characteristics

While the non-White and Hispanic population of Maine is less than 2% of the total population, more than 6% of AIDS cases have occurred among minorities. Through 1998, these included 25 cases among African-Americans/Blacks (0.4% of population vs. 3% of cases) and 20 cases among Hispanics (0.6% of population vs. 2% of cases).  Both Asian/Pacific Islanders and American Indian/Alaskan Natives are also over-represented, with approximately 1% of reported cumulative AIDS cases for each population.  The chart below shows cumulative Maine AIDS cases by race:

For all non-white AIDS cases, 42% had male-male sexual HIV risk, and 30% had history of injecting drug use.  The following charts show mode of transmission for African-Americans/Blacks, Hispanics, and "other people of color (POC) diagnosed with AIDS in Maine.  The category "other people of color" include Asian/Pacific Islander (n=3) and American Indian/Alaskan native (n=7) cases.

Region of Residence at Diagnosis:  The Charts below show region of diagnosis for African-Americans, Hispanics, and other People of Color.  In the charts "Southern" pertains to residence in either York or Cumberland Counties at time of diagnosis; "Central" denotes residence in Androscoggin, Franklin, Kennebec, Knox, Lincoln, Oxford, Sagadahoc, Somerset or Waldo Counties; and "Northern" denotes residence in Aroostook, Hancock, Penobscot, Piscataquis or Washington Counties.

Age at Diagnosis:  The following chart shows age at diagnosis for African American/Black, Hispanic, and "other POC" AIDS cases.  As with many populations at risk, many people of color received AIDS diagnoses while in their thirties, meaning that many were infected while in their early twenties or late teens.

African American/Black Behavioral Characteristics:

Certain behaviors may increase the level of risk for African American/Blacks, including:

• African Americans/Blacks who abuse alcohol, prescription drugs and illegal drugs including injecting drugs
• Incarcerated African Americans/Blacks
• African American males who have sex with males
• Sexual partners of the above

African American/Black Demographic Characteristics: 

• According to the 1990 census data, there were 5,000 African Americans/Blacks in Maine

• Estimates and observations suggest there has been a gradual increase in numbers since that time

• Although not all African Americans/Blacks fall into these categories, three significant reasons for re-locating to Maine or living in Maine are thought to be:

• Job opportunities

• Stationed here in the military

• Historic and family connections

• Existing social networks are largely connected to churches and other organizations such as the NAACP

• Individuals considered to be African American/Blacks are often bi-racial, or tri-racial.

• There are many bi-racial families and children

• Many are economically disadvantaged

 American Indian Behavioral Characteristics:

Certain behaviors may increase the level of risk for American Indians, including:

• American Indians who abuse alcohol, prescription and illegal drugs, including injecting drugs.

• Incarcerated American Indians

• American Indian males who have sex with males

• Sexual partners of the above

American Indian Demographic Characteristics:

• There are three reservations in Maine.  Two Passamaquoddy reservations:  Pleasant Point and Indian Township in Washington County, and one Penobscot reservation: Indian Island in Penboscot County.  The Micmac and Maliseet Tribes are both located in Aroostook County, but do not have reservations.

•  Estimated numbers range from between 8,000 to 10,000 which include those who are not indigenous to Maine, and are quite different numbers than those collected by state or federal entities.

• There are off reservation clusters in the general areas of Portland, Bangor, and Washington County 

• American Indian migrant workers are originally from both the US and from Canada

• Many American Indians are mobile, traveling back and forth across the Canadian border.  Some of this mobility is due to seasonal employment.

 Hispanic Behavioral Characteristics:

Certain behaviors may increase the level of risk for Hispanics, including:

• Hispanics who abuse alcohol, prescription and illegal drugs, including injecting drugs

• Incarcerated Hispanics

• Hispanic males who have sex with males

• Sexual partners of the above

 Hispanic Demographic Characteristics:

• The 1990 data indicated Hispanic comprised .6% of the population of Maine

• Exact number of people who are Hispanic are not known.  Two complicating factors are lack of accurate data of individuals who may be illegal immigrants, and migrant workers may not be accurately accounted for.

•  Many residents initially were, or currently are, migrant workers

• Migrant workers are located throughout the State of Maine.

•  There are other individuals of Hispanic ethnic heritage who are well established with a wide range of jobs, professions and incomes.

• Known cluster locations exist in Turner, Orland, Portland and Lewiston.

 Needs for People of Color at Risk

The following list of needs has been developed through a review of available literature relevant to the three populations, and through both professional knowledge and personal experience with these populations within the state of Maine.

The following is a list of needs which appear to be consistent for all People of Color.  Highest priority needs are in bold typeface:

•  Increased awareness of risk for HIV infection is imperative for members of each population, along with awareness that HIV is not just a "gay" disease.

• Access to affordable/no cost HIV testing and counseling. 

• Language-appropriate signs, symbols or rituals which clearly relay the information to people of color in culturally appropriate ways.

• Culturally competent prevention services, offered by members of the ethnic or racial community with whom individuals identify.

• Recognition and addressing of the negative effects of systemic racism and discrimination of people of color upon prevention and health service provision.

• Acknowledgement and addressing of homophobia among people of color, particularly among leadership and in community support groups.

• Education about, and a response to, the connections between substance use and abuse and HIV risk for each population.

•  Information available in a low-literacy format.

• Increased awareness of the connections between and among sexually transmitted diseases (STDs), unintended pregnancies, substance use and abuse, and HIV.

Specific needs for each POC population are listed here, with high-priority needs in bold typeface.

• American Indian specific needs include:

• Materials responsive to the particular needs of each tribe in Maine.

• Easy access to affordable and confidential HIV counseling and testing.

• Increased awareness that HIV/AIDS is a American Indian problem is needed

• Increased awareness of the connections between and among sexually transmitted diseases (STDs), unintended pregnancies, substance use and abuse, and HIV.

• Non-native providers who are culturally competent.

• American Indian providers who can provide culturally specific education.

African American/Black specific needs include:

• Recognition by the churches and Black community groups that HIV in Maine as an issue relevant to their members and community.

•  Increased understanding by members of the populations that being in Maine does not prevent HIV infection.

• Community-building for the many African-Americans who have recently relocated to Maine from elsewhere in the United States or from foreign countries.

• Culturally competent providers.

• Transportation and childcare during HIV prevention-related activities.

•  Easy access to clinics and other sources of confidential testing and counseling and follow-up.

 Hispanic specific needs include:

• Transportation and childcare during HIV prevention-related activities.

• Addressing language-specific barriers.

• Low-literacy, language-specific literature.

• Addressing the affect of cultural "machismo" on HIV prevention.

• Attention to the needs of migrant populations.

• More behavioral data.

• Culturally competent providers.

• Easy access to clinics that provide confidential testing and counseling by providers fluent in Spanish.

Prioritized Interventions for People of Color at Risk:

The interventions listed below are based on a limited review of the literature and the best thoughts and intentions of the Community Planning Group, Statewide CPG Needs Assessment, and research about these populations.  It is important to note that research on effective interventions for African Americans and Hispanics focuses primarily on prevention efforts in urban settings.  Rural-based research for these populations is limited.  Prioritized interventions are listed below in order of priority:

1. Community building for People of Color.

2. Outreach activities to create and deliver a mass education campaign for POC.

3. A systematic needs assessment process to obtain accurate and current behavioral information about POC.

4. Bi-cultural, (culturally appropriate) individual-level HIV risk-reduction counseling.

5. Group-level HIV risk-reduction counseling.

6. Build capacity of organizations currently providing services, both AIDS service organizations and other community-based organizations.

7. Provide culturally competent and relevant information to statewide hotlines.

Linkages

The following list identifies a variety of ways in which information about or relevant to the People of Color populations and HIV infection risk in the state of Maine is connected to the Community Planning process, and accessible to Community Based Organizations(CBOs).

• Epidemiologic Surveillance: The surveillance coordinator of the state of Maine, Mark Griswold, is the Public Health Co-Chair of the CPG.  He compiles data specific to this population and provides to both the CPG and Community Based Organizations as requested. 

• Local behavioral surveillance data does not exist for any of these populations

• Research by the CPG has included focus groups of three of the five American Indian tribes indigenous to Maine, and limited literature reviews of HIV prevention efforts for African American and Latino/as in other regions of the country have been performed.

• Needs Assessment Data:  Needs assessment is available concerning the HIV prevention needs of people of color.

• In addition to the above, CPG members provide linkages to community-based organizations, personal contacts, professional knowledge, personal experience, and the like.

Linkages between Primary and Secondary Prevention

There are no formal linkages between primary and secondary prevention for People of Color.  Five AIDS Service Organizations  which provide both HIV Prevention and Case Management services are located statewide.  These organizations include:

• The AIDS Project (TAP) in Portland, located in the southern section of the state and providing services to Androscoggin, Cumberland, Oxford, and York Counties

• Down East AIDS Network (DEAN), located in Ellsworth, and serving Washington and Hancock Counties.

• Eastern Maine AIDS Network (EMAN),  located in Bangor and serving Aroostook, Penobscot and Piscataquis Counties.

• Coastal AIDS Network (CAN - formerly Waldo-Knows AIDS Coalition) located in Belfast, serving Waldo and Knox Counties with case management, and prevention services to Waldo, Knox and Lincoln Counties. 

• Dayspring AIDS Support Services, located in Augusta, provides case management and HIV prevention services to Kennebec, Somerset, Sagadahoc, and Franklin Counties.

Additionally, all Counseling, Testing and Partner Notification and STD Clinic services provide direct linkages with resource and referral options for both HIV- and HIV+ individuals.

7.2.5   Youth at Risk

Population Description

The noun youth is used to be inclusive of young people who are age 24 and under and who exhibit high-risk behaviors or who are in situations which place them at higher risk for HIV infection.  The following lists, not exhaustive, includes epidemiologic, behavioral and demographic characteristics of youth at highest risk of HIV infection, reinfection or transmission.  Since youth at risk may be any race, gender, ethnicity or sexual orientation, and may also have special needs, information pertinent to youth at risk may be found in each of the five other population sections.

Epidemiologic Characteristics:

Age at Diagnosis:  Among those diagnosed at age 30 or under (not including pediatric cases), more than half (62%) were MSM.  Other significant modes of transmission for this group include heterosexual transmission (15%) and injecting drug use (9%).  Another 5% had combined MSM and IDU transmission risk.  The following chart shows mode of exposure for males and females less than 30 years old when they received AIDS diagnoses:

Region of Residence:  Fifty-five percent of people under 30 diagnosed with AIDS in Maine (not including pediatric cases) resided in either York or Cumberland Counties.  Another 32% lived in Central Maine (Androscoggin, Franklin, Kennebec, Knox, Lincoln, Oxford, Sagadahoc, Somerset and Waldo Counties) and 13% lived in Norther Maine (Aroostook, Hancock, Penobscot, Piscataquis and Washington Counties).

Youth Risk Surveys:  Recent surveys of youth also show the presence of HIV risk behavior.  A 1997 Youth Risk Behavior Survey conducted by the Maine Department of Education revealed that 52% of Maine high school students were sexually active, with 59% of females and 55% of males becoming sexually active by age sixteen.  Fifty-four percent (54%) of students who have had sexual intercourse report using a condom at the last time of intercourse.  

Likewise, a 1999 study  of out-of-school youth in Maine indicates that the  average age of first penile-vaginal intercourse was 13.5 years.  In addition, approximately 20% of females reported their first experience with penile-vaginal intercourse was non-consensual; likewise, of those who reported receptive anal intercourse, 20% reported that their first experience was non-consensual.  Of those surveyed, 1/2 to 1/3 used condoms at last intercourse, but 1/3 of respondents never or rarely use a condom.

STD Infection:  Infection with Chlamydia trachomatis is the most commonly reported sexually transmitted disease in Maine.  While Chlamydia infection is not in and of itself considered a marker for HIV risk, it is a marker for unprotected sexual activity, and high Chlamydia rates among Maine teenage girls are of particular concern.  Forty-five percent of female c. trachomatis infections were reported among females between 15 and 19 years old.

Behavioral Characteristics:

Youth who engage in unprotected sexual HIV risk behaviors who:

• Are gay, bisexual, transgender, or questioning males

• Are sexually active

• Have multiple sex partners

• Exchange sex for goods/services

• Use alcohol and other drugs

 Or youth who share needles for:

• injecting drug use

•  tattooing

• piercing

Or youth who are the unprotected sexual partners of people who engage in any of the abov