Houston, We Have An HIV Problem

On World AIDS Day 2016, Sylvester Turner vowed to “End HIV in Houston” by decreasing stigma and increasing testing in high-risk neighborhoods. But for a city as big as Houston, Texas (which has approximately 2.3 million residents, according to the 2016 census — and is the fourth largest city in the nation), to combat HIV and stigma, building more shelters and supplying more HIV tests isn’t enough. It’s going to take, quite literally, a village.

Shattering stigma costs money, especially in Houston, where suburbs are spread across more than 600 square miles, and high-risk populations are also scattered. Last year, more people moved to the area than to any other city in the U.S.

Prior to Hurricane Harvey, Houston made significant progress in reducing homelessness. According to a 2015 report from The Coalition for the Homeless, homelessness in the area had dropped by 46 percent since 2011.

Gentrification has fed economic growth, even in neighborhoods where it previously wilted. According to local activists and organizers, it has also created a façade that HIV no longer exists, when in fact the city has the most new diagnoses in the state: 1,282 in 2015 alone.

According to local activists, most of the Houston Health Department’s budget goes towards treatment, rather than HIV prevention, which makes it hard for them to put out effective prevention marketing strategies. Kelly Young, CEO of AIDS Foundation Houston, says the organization only receives $150,000 annually from the city to enact its prevention programs. And AFH can only receive that money if they meet an odd quota: a two percent rate hike in the number of new HIV diagnoses, otherwise their budget gets cut.

“We’re targeted to go to the most high-risk people, but that’s all the money is for,” Young explains, adding that social workers work with what they have, but there is not enough money, nor resources,  for “broad, saturated marketing campaigns around HIV.”

Young adds, “People come up to us all the time, saying, ‘Why aren’t you doing this? Why aren’t you doing that?’ I’d love to do that but my tester is literally out from Wednesday night to Saturday night at [bars]… trying to get that two percent rate. Everything else we do on top of that is stuff we have to raise money for.”

According to local statistics provided by the Salvation Army of Greater Houston, 60 percent of youth experiencing homelessness were kicked out by a family, relative, or foster parent. Another 16 percent ran away, and 12 percent aged out of the foster care or juvenile justice systems. The majority, 76 percent, don’t have a job in any capacity.

Statistics also showed that 51 percent of youth experiencing homelessness use social media at least once a day, and 20 percent of them report they currently need mental health treatment. Given that many of them have experienced immense trauma in their lives (27 percent reportedly have PTSD, and 44 percent suffer from major depression), finding the courage to seek that treatment can be difficult. That’s where case managers come in: to act as an on-hand counselor who can drive them places, provide information, and help care for their medical needs.

In the state of Texas, 16-year-olds can consent to medical treatments without an adult and can receive transitional or emergency housing. But advocates say there isn’t enough encouragement or education to explain to young people that they have these rights.

LGBT youth “are sometimes afraid to ask for these services,” says Gerald Eckert, social services director of Salvation Army Houston. “If [case managers] are not walking them from the moment they’re tested to the clinic to get treatment, it’s unlikely to happen. We’ve been able to bridge some of that with volunteer nurses from the University of Texas School of Nursing. We’re also trying to get resources for not only PrEP, but also HPV-related cancer vaccines. These are things people have the will for, but it’s a matter of money.”

According to Young, AFH needs to raise $1.4 million a year in donations just to keep its offices open and pay its staff of social workers and case managers, who are literally the heart of the operation. Because of its financial limitations, many case managers have more work than they can handle.

“We test 1,200 people in a year with one tester or case manager,” Young says. “You have to hit a two percent [new diagnoses] rate or get cut. You’re drilling in to see where you really have to go, so when a person comes in who’s HIV-positive now, the case manager has to focus on them on top of their quota. Now they’re doing double duty, and they barely make enough to not be on food stamps themselves. It’s an interesting choice we make in our world to talk about humanity without looking at the people who really actually offer the humanity on a regular basis.”

One of Houston’s major HIV-prevention marketing strategies last year was to put up a few billboards around the city promoting PrEP, a daily pill strategy that, when taken routinely, prevents a user from contracting HIV. Young says Houston’s health department “works miracles with very little,” and had received money from the Centers for Disease Control and Prevention that it then gave to AFH to finance the public education campaign.

Eva Thibaudeau-Graczyk, program director at the Coalition for the Homeless, says one reason why LGBT youth aren’t highly informed about sexual health is a lack of sex ed — and a tendency to view sex as something people do, rather than a part of their health. Thibaudeau-Graczyk adds that a “healthy or an accurate sexual health education” has been absent from the school system for far too long: “We don’t fund that in our public schools… I think we’re not raising young people with fluency.”

“A young man called me once,” recalls Thibaudeau-Graczyk, sharing the story of a 19-year-old experiencing homelessness. “He grew up in foster care, struggled with mental illness, on and off with substance abuse, chose to [do sex work]. He called me and [had] tested positive. Someone was there to talk to him. He seemed pretty upbeat and educated [on HIV].”

Three months later, when the teen left the care of a case manager, depression and isolation kicked in, and he tried to commit suicide.

“You’re talking in these instances about meeting an entire spectrum and continuum of support and services,” Thibaudeau-Graczyk says about the importance of reworking budgets for the benefit of case managers. “It’s not just getting you in the door to get tested, it’s not just when you find out. That emotional and mental piece is the people side of things. And that’s what we discount when we only fund medical case managements.”

Another factor creating overarching HIV stigma is how medical professionals handle discussions. Following Hurricane Harvey, the city set up a separate system for poz people seeking medication. Although well-intended, it virtually segregated people with HIV, as if their chronic condition was entirely different from other chronic conditions, like diabetes.

“One of the reasons we have trouble getting people on PrEP is we have doctors not willing to prescribe it because they don’t understand, and don’t know that they can [prescribe it],” Young says. “It’s not that complicated and… you don’t need to be an infectious disease doctor anymore.”

Given that Houston represents a buckle in the Bible belt, local religious ideology tends to promote LGBT and HIV stigma. For the 60 percent of youth that have been kicked out of their homes, sharing their sexual identity has often created more harm than good.

Thibaudeau-Graczyk says, clients might want to avoid identifying as LGBT at many local agencies with more conservative religious approaches than the Coalition for the Homeless, Salvation Army, or AIDS Foundation Houston. (Though the Salvation Army was founded by Christian evangelicals, in recent years it has made efforts to be more LGBT inclusive and the organization has become a leader in caring for those who are HIV-positive. It’s also the largest provider of drug and alcohol recovery services in the country.)

Reaching LGBT youth remains a significant goal for Houston organizations, and as many case managers know, it all comes from being present and letting queer teens know someone cares. As Eckert points out, “People are harmed in relationship and people are healed in relationship. Without the relationship there is no healing.”