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Background facts
An estimated 41% of Americans with HIVAIDS live
in the South. As of 2005, the U.S. Centers for
Disease Control and Prevention (CDC) reported
that HIV prevalence rates in Georgia, Florida,
and Louisiana had surpassed 200 per 100,000 people,
a higher rate than anywhere in the U.S. except
the Northeast and the Caribbean. The CDC also
documents HIV infection rates -- the sign
of the AIDS epidemic to come -- to be extremely
high in Florida, Louisiana, Mississippi, and
South Carolina. The Mississippi Delta has the
highest rates of heterosexually-acquired HIV
in the U.S., as well as the highest proportion
of HIV diagnoses among young people aged 13-24
years (18.4%). More than three quarters of people
diagnosed with HIV in the Mississippi Delta and
the Southeast Region are African American, and
diagnosis rates are higher among African Americans
and Hispanics than whites in all regions.
Data from an HIV Cost and Services Utilization
Study published in 1999 by the Rand Corporation
indicated that only one-third to one-half of
people living with HIV/AIDS were in regular HIV
care as of 1996, and that these rates were worse
in the Southern U.S. The Institute of Medicine
in 2004 suggested that
the combination of financing structures
and individual characteristics such as race/ethnicity
and low income level interact to exacerbate disparities
in health care. Fewer than half of the
people in the South who meet government criteria
for use of antiretroviral treatment are likely
to be receiving these drugs, and a significant
share of people who have HIV and AIDS are tested
too late in the course of disease to benefit
from early care.
Experts note a particular need and opportunity
for philanthropic grant making for:
· Education and advocacy focused on HIV treatment and care in rural
areas: In the rural U.S., HIV patients are more likely than their urban counterparts
to see physicians who have treated few people with HIV and are less likely
to have experience with the newest advances in combination antiretroviral therapies.
Treatment education and advocacy programs can help improve quality of care
and increase positive outcomes of HIV treatment.
· Community-based organizing related to HIV/AIDS: Community organizing
and advocacy may help to reduce stigma related to HIV, link HIV to broader
issues of civil rights and economic justice, and persuade people to acknowledge
their risk, seek testing, engage in treatment, and call on rural health providers
to create and deliver HIV services.
· State-level and municipal policy work: Allocation of HIV prevention
and treatment funding distributed by the CDC, the Health Resources and Services
Administration and other federal agencies is often guided at a state and local
level. In the South, state governments are responding to fiscal pressures by
reducing or restricting Medicaid benefits, imposing cost sharing requirements
(including increasing Medicaid co-payments), and implementing controls on pharmacy
costs. These measures, combined with delayed eligibility for both Medicaid
and Medicare, create structural barriers to appropriate care by discouraging
providers from treating poor individuals with HIV.
EJAF investments:
According to Funders Concerned About AIDS, the
Elton John AIDS Foundation and the National AIDS
Fund are among the leading 10 grant makers currently
investing small HIV/AIDS grants in the Southern
U.S. region. During 2007, in partnership with
the National AIDS Fund and the Ford Foundation,
EJAF invested more than $550,000 to support community-based
HIV/AIDS efforts in the South.
Addressing HIV in the Caribbean and Latin America
Background facts:
As many as 230,000 people are currently living
with HIV in the Caribbean. An additional 1.6
million people are living with HIV in Central
and South America, with major epidemics in Brazil,
the Andean countries, and Central America. The
Caribbean is the second-most HIV/AIDS affected
region in the world after sub-Saharan Africa,
containing nine of the 12 countries with the
highest HIV prevalence in the Americas. In 2007
alone, 17,000 people in the Caribbean were newly
infected with the virus. More than 100,000 people
in Latin America became newly HIV-infected last
year as well.
In the Caribbean, AIDS has become the leading
cause of death among adults aged 15 to 44 years.
An estimated 11,000 people died of AIDS in the
region in 2007, and most of these deaths were
avoidable. Fewer than one in ten HIV-positive
individuals know their serostatus, and relatively
few people are receiving HIV treatment. Across
the Americas, the highest HIV-infection levels
among women are in the Caribbean. Overall, HIV
transmission in the Caribbean is occurring largely
through heterosexual intercourse, but, among
men, approximately 20 percent of HIV infection
is reportedly due to sex with other men. By contrast,
in Central and South America, UNAIDS states that
male-to-male sex is the primary driver of epidemics
in many countries. Stigma and discrimination
related to HIV/AIDS is high, as are rates of
poverty, lack of access to health care, and prejudice
against homosexuality, impeding HIV prevention
efforts and access to care.
The epidemic is not evenly distributed across
Latin America and the Caribbean. Brazil alone
accounts for one third of the region's
people living with HIV/AIDS and one third of
all new infections. In the Caribbean, the overwhelming
majority (an estimated 190,000) of people living
with HIV reside in four nations: Haiti, the Dominican
Republic, Jamaica, and Trinidad & Tobago.
In addition to these countries, HIV prevalence
is higher than the regional average in most of
Central America, in Guyana and Suriname, an din
several Caribbean nations such as the Bahamas
and Barbados.
In Haiti, the number of people living with HIV
in 2006 was 180,000, translating to a rate of
3.8 HIV+ adults out of every 100 adults in the
country. Life expectancy at birth in 2010 is
projected to be 10 years less than it would have
been without AIDS, and political unrest and deep
poverty have limited the ability of the Haitian
national government or local communities to effectively
address HIV and other health concerns. In the
Dominican Republic, 62,000 people are estimated
to be living with HIV/AIDS; the national infection
rate is estimated at 1.1 percent, with rates
much higher in selected communities (for example,
the rate of HIV among MSM is documented at 12%).
Trinidad & Tobago has the third highest number
of HIV/AIDS cases in the Caribbean, with 26,000
people (2.6% of the adult population) living
with HIV. Across the region, fewer than one in
ten HIV-positive individuals know their serostatus,
and relatively few people are receiving HIV treatment.
EJAF investments:
According to Funders Concerned About AIDS, Latin
America and the Caribbean receive only 1% of
all international HIV/AIDS grants made by the
largest 50 U.S. HIV/AIDS-focused philanthropies.
Private U.S. philanthropic organizations have
an important role to play in catalyzing new responses
to HIV in Latin America and the Caribbean, in
part due to geographic proximity and strong cultural
ties with immigrant communities in the United
States.
In 2007, EJAF was one of the largest investors
of private philanthropic dollars to the Caribbean
and Latin America, investing more than $1.6 million
through partnerships with Kaiser Family Foundation,
the HIV Collaborative Fund, the Foundation for
AIDS Research, and other partners.
HIV Prevention among Injection Drug Users
Background facts:
People infected through injection drug use account
for more than 20% of AIDS diagnoses and represent
approximately a quarter of all people living
with AIDS in the United States. In the United
States between 1999 and 2002, injection drug
use was the second leading cause of HIV infection
for women (20.3% of all infections) and the third
leading cause of HIV infection for men (15.8%
of all infections).
Harm reduction efforts are a highly effective
method to provide HIV prevention interventions
to women and men who are either HIV+ or at risk
for HIV. For more than a decade, data has shown
that sterile injection equipment exchanges (SEPs
or NEPs) and associated harm reduction counseling
and support programs reduce risks of HIV transmission.
Harm reduction programs are an important way
to stop injection-related HIV infections and
provide a low-threshold entryway into drug treatment,
counseling and interventions for sexual risk
reduction, support for antiretroviral access
and use, and other health and economic interventions.
Federal law prohibits the use of federal funds
for NEPs. A study released by CDC in 2005 reported
that, as of three years earlier, public financing
for NEPs had declined and the number of syringe
exchange programs in the U.S. had decreased for
the first time in eight years. Still, the study
found that the number of total syringes exchanged
and total NEPs budgets across all programs had
increased just as the federal response to the
challenges of substance abuse has waned.
In a recent victory for syringe exchange advocates,
President Bush signed legislation on December
26, 2007, lifting a nine-year ban on city funding
for syringe exchange programs in the District
of Columbia. Federal spending bills since 1998
made Washington, DC, the only city in the nation
prohibited from using either federal or local
taxpayer dollars to fund such programs, even
though the use of unsterile syringes by injection
drug users is the second leading cause of HIV
infection in the District of Columbia, which
has the highest HIV infection rate in the country.
With the ban lifted, the city plans to devote
$650,000 from its budget to the expansion of
syringe exchange programs.
A select group of philanthropic funders, including
the Levi Strauss Foundation, the Irene Diamond
Fund, the Tides Foundation, and the Elton John
AIDS Foundation have stepped forward to mobilize
new funding for HIV prevention related to harm
reduction and injection drug use. In recent strategic
interviews, many experts have commended this
investment and have recommended a continuation
and increase of this effort. In addition, experts
have suggested that drug-related harm reduction
programs are also needed for gay men, particularly
related to the use of methamphetamine.
EJAF investments:
Since 2006, EJAF has been a major partner in
the Syringe Access Fund, a $1.3 million annual
collaboration of the Levi Strauss Foundation,
Irene Diamond Fund, National AIDS Fund, Public
Welfare Foundation, and Tides Foundation. EJAF
will continue to serve as a sustaining core partner
in this effort, supporting more than 50 organizations
each year who work to prevent HIV/AIDS by reaching
injection drug users with sterile syringes and
other harm reduction interventions.
Addressing HIV in Prison and Re-Entry Programs
Background facts:
The United States has one of the highest incarceration
rates in the world; the number of individuals
in prison and jail passed two million in 2002.
Prisoners are heavily stigmatized and poorly
served; most are non-violent offenders. Approximately
60% of federal prisoners and more than 20% of
state inmates are in custody on drug charges,
in many cases low-level crimes. Furthermore,
the burden of incarceration falls unevenly. An
estimated 12% of African-American men between
20 and 34 are behind bars, more than seven times
the rate for white men the same age.
Rates of HIV and hepatitis C infection are high.
According to the CDC's Morbidity and Mortality
Weekly Report, HIV prevalence rates among prison
populations in 2002 was over 1% in Federal prisons
and over 2% in state prisons. Among 5,000 prisoners
in New York State, 7.2% of men and 13.6% of women
had HIV or AIDS. In Florida, the corresponding
rates were 3.6% and 7.4%. In Georgia, 2.3% and
3.2%. As stated by the National Commission on
Correctional Health Care in January 2003, "inadequate
health care in U.S. correctional facilities poses
a serious threat to the nation's public
health. Furthermore, research in 2003
involving HIV-positive inmates has indicated
that they often have unprotected sex before and
after incarceration.
Prison health advocacy can work and is needed.
An August 2005 Bureau of Justice Statistics study
found that the AIDS-related death rate in jails
and state prisons significantly decreased over
the last several years, due largely to improved
medical treatment and lawsuits filed by advocacy
groups to improve conditions behind bars. Recent
state-level advocacy brought about a 2005 Illinois
law mandating jails to offer HIV testing at no
cost to inmates, and to provide case management
and referrals for support services to HIV-positive
prisoners when they are released from prison.
Specific advocacy work can be supported that
includes:
· Policy research and quality data collection about prison health expenditures,
prison health service delivery, and prison health outcomes.
· Public advocacy and communications work to increase the transparency
of prison health programs, identify potential actions and individuals responsible,
and hold state and federal government agencies and prison health contractor
companies accountable for prisoner health.
· Communications work to articulate and frame the issues, increase public
awareness, and to present data, case studies, stakeholder opinions, argument,
and ethical/moral imperatives.
· Community organizing work among prisoner families and health advocacy
groups to mobilize constituencies, build coalitions, and advocate through litigation,
legislation, and communications.
EJAF investments:
Private foundation funding is urgently needed
to monitor and improve prison health programs
and prisoner re-entry programs in the United
States, aiming for quality and accessibility
of HIV counseling and testing, HIV and TB treatment,
sound HIV prevention, and related health care.
Beginning in 2007, in partnership with National
AIDS Fund, EJAF supported the launch of a major
national small grants program on these issues.
In addition, EJAF is now supporting the ACLU
National Prisons Project and Human Rights Watch
to work in this area. In total, EJAF's
2
007 investment was $635,000.
Addressing HIV among Men Who Have Sex With Men
(MSM)
Background facts:
In the U.S., Caribbean, and Latin America, MSM
continue to account for a disproportionate percentage
of new HIV infections and AIDS diagnoses. According
to CDC data on new HIV-infections in the United
States, the most prevalent mode of HIV exposure
among HIV-infected men continues to be sexual
contact with other men (51% in 2005). In the
Caribbean and Latin America, research is documenting
that more than 25% of all new HIV infections
are among MSM. Younger MSM are likely to be HIV
infected without knowing it. A recent study found
that 77% of young MSM who tested HIV positive
believed they were not infected. Also, new statistics
released by the New York City Department of Health
and Mental Hygiene indicate that the number of
new HIV diagnoses among gay men under age 30
rose 32% between 2001 and 2006, and among black
and Hispanic gay men, the figure was 34%; HIV
rates among the youngest gay men in the study Ð ages
13-19
Ð doubled during this period. Despite all
evidence demonstrating that condom use can reduce
sexual transmission of HIV, and that individual,
group and community-level interventions can reduce
HIV risk behaviors, a disproportionately small
amount of funding is dedicated from government
and private sources to interventions targeting
gay men and MSM.
In the United States, black gay men are a major
and disproportionately high proportion of MSM
who are becoming infected. According to the CDC,
the leading cause of HIV infection among African
American men is sexual contact with other men.
A report released by the Black AIDS Institute
and the National Association for the Advancement
of Colored People in 2006 called for an end to
debilitating stigma that helps HIV spread in
the black community, noting that stigma undermines
prevention and treatment efforts, Òparticularly
in the South and among gay and bisexual men.
In March 2007, the CDC announced plans to expand
and improve HIV prevention and treatment programming
for African Americans, but these plans do not
represent the full scale effort that is needed.
Continued high HIV prevalence rates among gay
men in the U.S. and in the Caribbean and Latin
America, coupled with an insufficient government
and community response, has led to an accelerated
sense of crisis both within and outside of networks
of gay men. Many organizations have issued calls
for action, including calls to:
· Increase efforts to reach gay and bisexual men through HIV testing,
STD screening, primary medical care and behavioral interventions.
· Increase research documenting effective HIV prevention strategies
and behavioral interventions, and increase efforts to adapt and tailor current
evidence-based interventions for gay and bisexual men.
· Enhance access for gay/bisexual men to primary medical care, STD treatment,
and immunizations.
· Increase access to substance abuse treatment and mental health services
for gay and bisexual men, regardless of their HIV status.
EJAF investments:
In 2007, EJAF made investments totaling $435,000
on this topic, including support for two new
initiatives, a grant to Black AIDS Institute
to contribute to the national Black AIDS Mobilization,
a multifaceted campaign to address HIV among
black Americans, and support to amfAR for the
Caribbean and Latin American launch of the MSM
Initiative, a small grants program targeted to
local peer-led HIV prevention, treatment, and
care efforts among MSM in that region.
Improving Sexual Health Programs for Youth
Background facts:
In the United States, half of all new HIV infections
are among people under the age of 25. Adolescents
and young adults also account for the majority
of new HIV infections throughout the world. Nationwide
in the U.S., 87.9% of students have been taught
in school about acquired immunodeficiency syndrome
(AIDS) or HIV infection. But, according to CDC
surveillance, adolescents and young adults continue
to face substantial risks, illnesses and social
problems related to unintended pregnancies and
STIs, including HIV infection. Surveys continue
to show approximately half of high school students
reporting having had sexual intercourse, and
a third of high school students reporting being
currently sexually active (having had sex during
the preceding three months). More than a third
of these sexually active high school students
report not using condoms at last sexual intercourse.
These rates are documented to be higher among
high school students who are poorer and who are
African American.
Funding is needed for programs that improve
sexual and reproductive health options for youth.
An array of individual studies and meta-analyses
have determined that comprehensive sex education
programs that include information about both
abstinence and contraception can be effective
at helping young people reduce their number of
sexual partners, increase condom use when they
do have sex, and delay the onset of sexual intercourse.
Abstinence-only programs do not work. A wealth
of studies and program evaluations have failed
to find abstinence-only programs to be effective.
However, since 2000, the federal government continues
to spend hundreds of millions of dollars on abstinence-only-until
marriage programs, and it is estimated that schools
in over a third of public school districts use
an abstinence-only curriculum. Many high schools
do not make condoms readily available to teenagers,
even though research has found that in schools
where condoms are available students are less
likely to be sexually active and more likely
to use condoms if they are having sex.
Gay youth are at particularly high risk of HIV
infection. Funding is needed to meet the HIV
risks of gay youth by addressing homophobia as
a civil rights issue and a barrier to HIV prevention
and care. Even the U.S. CDC has acknowledged
that stigma surrounding HIV/AIDS leads individuals
to: deny risk; avoid testing; delay
treatment; and suffer needlessly. The
agency has identified a variety of ways in which
homophobia affects HIV prevention efforts, from
the individual at risk of infection who may deny
their risk because of internal conflicts, to
the broader culture, which delivers anti-gay
messages, [and] institutionalizes homophobia
through laws that regulate intimate sexual
behaviour, and lags in its support of sensitive
and honest prevention for gay and bisexual youth,
young adults and older men.
EJAF investments:
During 2007, in partnership with Advocates for
Youth, Urban Tech, and other partners, EJAF invested
more than $550,000 in this funding area.
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