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HIV Commission elects all-white leadership
TPAC in crisis over funding cuts
PWAs to get role in system evaluation
Clinton ups budget for HIV prevention
TB among HIV+ varies by region
HIV Commission elects all-white leadership
The Philadelphia HIV Commission -- which is responsible for the setting of priorities for the allocation of over $7 million in federal Ryan White Title I AIDS funds in the region -- has elected an all-white leadership for the Commission and its various subcommittees.
With the election of Mark Davis, of Philadelphia, and Mick Maurer, of Bucks County -- both HIV+ white men -- by a single vote at a heated Commission meeting in mid-January, the Commission defeated an effort by James Roberts, executive director of the Minority AIDS Project of Philadelphia (MAPP), to become co-chair of the group.
In addition to its new co-chairs, the Commission had previously chosen white co-chairs of the Commission's Care Committee (Julie Davids and Bryan Cole Smith), which discusses priorities for the allocation of AIDS direct care funding, and a white community co-chair of the Commission's HIV Prevention Community Planning Group (CPG), Joe Cronauer of We The People. Under rules established by the U.S. Centers for Disease Control and Prevention, a local health department representative is required to serve as the other co-chair of the CPG. Health Commissioner Estelle Richman had previously appointed Jesse Milan, an African American gay man who is director of the city's AIDS Activities Coordinating Office, as the city's representative on the panel.
The almost evenly-divided HIV Commission vote for co-chairs reportedly broke mostly along racial lines, with the overwhelming majority of blacks voting for Roberts and most of the whites voting for Maurer as a co-chair. Davis, who had already been serving as interim consumer co-chair, had been elected to the other co-chair position on an earlier ballot.
"The Commission's action brings into serious question the viability of the Commission as a credible planning council for HIV care and prevention funding, in light of the preponderance of AIDS cases in the African American and Latino communities in the region." said Gerald Wright, a spokesman for MAPP. In Philadelphia, over 70% of AIDS cases have occurred in minority communities. Wright said that the issue was not whether the whites elected to the various Commission posts were competent or sensitive to minority communities, but why the HIV planning process has consistently rejected black leadership since its inception.
Minority AIDS advocates have complained since 1990 that the HIV planning council process has discriminated against minority communities both in representation in the planning process and in the identification of organizations to provide AIDS services. While many minority groups receive funding for HIV prevention activities, few direct care dollars are allocated to minority community organizations when compared to the preponderance of AIDS cases in minority communities.
At its meeting the previous month, the Commission adopted a plan for AIDS allocations in 1997 that called for a major increase in funding for African American AIDS services. Roberts and other Minority AIDS Project advocates had led the effort to include the increase in the 1997 plan, although it remains unclear whether the city intends to go along with the re-allocation of current funding for white-led organizations which would be required.
MAPP, claiming that the Commission process has traditionally been biased against supporting AIDS services in the black community, has instead called for Commission funding for an independent African American AIDS planning council which would determine priorities for AIDS care and prevention and allocate funding to service agencies led by people of color.
"Even now, in 1997, sixteen years after it became clear that the impact of AIDS was greater in minority communities, the AIDS planning process continues to reject the leadership of people of color. The Commission's action continues the tradition of entrusting to white people the major power over who lives and dies in our communities," said Wright.
The Commission experience has been rocky from its start in early 1996. It was formed after Richman revoked the responsibility for AIDS planning for Ryan White CARE Act Title I funds which had been held since 1990 by The Philadelphia AIDS Consortium (TPAC), after racism and corruption charges had paralyzed the group. Richman was then criticized for appointing few experienced AIDS advocates from the African American community to the new Commission, while re-appointing whites who had served in the discredited TPAC process.
African American members of the Commission are said to be considering asking for federal intervention from the Health Resources and Services Administration (HRSA) to force the city to assure more influence for people of color in the AIDS planning process. HRSA official Eric Goosby told a meeting of over 400 African Americans in North Philadelphia last year that HRSA placed a high priority not only on formal representation in the AIDS planning process, but active leadership of minority people in the process.
TPAC in crisis over funding cuts
Citing "serious discrepancies" between the process sanctioned by the board of directors of The Philadelphia AIDS Consortium (TPAC), and the process actually implemented by its staff to eliminate funding for four AIDS projects in Philadelphia and Chester County, TPAC president Joe Cronauer announced this week in a memo to the TPAC board that he was suspending the funding cut in order to give the organizations affected "a reasonable and adequate opportunity" to develop a plan to resolve their problems.
At a meeting of the TPAC board on January 14th, TPAC Contracts Manager Miriam Peterman and Executive Director Larry Hochendoner had reported that four organizations had so seriously failed to provide services required in their contracts that they were asking that they be de-funded if the organizations could not submit an action plan which adequately addressed their shortfalls.
In a memo to TPAC board members on January 17th, Cronauer reported that the Board had "clearly specified that agencies facing potential defunding would be given adequate opportunity to respond to the findings of TPAC staff...with an action plan," and that defunding would only occur after a formal evaluation of the corrective actions described by the organizations. Instead, Cronauer said, "agencies were notified in a letter dated the day after our Board meeting (his italics) that they would be defunded." Cronauer said that after he investigated complaints from the groups, it became clear that "none of the agencies were notified at all...that they were required to submit an action plan or face potential defunding." Peterman and Hochendoner had earlier told the Board that such notices had been sent, that groups would be given the opportunity to submit corrective action plans, and that they were aware that their funding was threatened.
Dan Daniel, board president of the Chester County AIDS Support Services (CCASS), one of the organizations which disclosed it was a target of the defunding process, said that his organization received the notice of defunding in the same envelope as the report of TPAC's site review team noting deficiencies in the project's implementation. The envelope was delivered by messenger, he said, on the day after the TPAC board meeting.
Cronauer also noted in his memo that at a meeting of a board committee on January 16th, which was called to ratify potential new agencies to receive the funding, "inadequate/incorrect information" was provided, "potentially skewing the decisions as to what alternate agencies might best serve the community." Sources at that meeting said that board members were incorrectly told that one of the potential beneficiaries was guilty of serious fiscal irregularities, had closed its doors and its executive director had resigned. The organization is, in fact, still operating and its executive director remains in place.
Other representatives of the affected agencies charged that they were being targeted for defunding not because of poor performance, but because of bias on the part of TPAC staff. An application from the agency which the board committee was told was closed was "lost" by TPAC staff in a funding allocation process in 1995. In another incident in 1995, TPAC staff actively resisted an allocation to CCASS, instead attempting to shift the funds to another Chester County group.
Cronauer said that "it is clear in this case the motion of the board regarding potential defunding of these agencies was not carried forth in a manner consistent with the wishes of the board."
Controversy over TPAC's ability to make allocations decisions has followed TPAC throughout its history. Charges of conflict of interest, staff bias, and racism derailed each funding allocation process conducted by TPAC since its beginning in 1990. In 1993, federal officials demanded that TPAC eliminate conflicts of interest in its allocation process, and in 1996, health commissioner Estelle Richman removed authority for Ryan White Title I allocations from the group.
TPAC now controls only Ryan White Title II funding -- which is generated by the state -- and state HIV prevention funding, called "106" funding for its line number in the state budget. The new TPAC, which was re-formed in 1996, has through its bylaws taken away its own ability to directly make allocations decisions. The exception to this rule is in rare instances where a small amount of money is available and the board determines that prompt action is necessary because of extenuating circumstances such as underspending by agencies or, as in this case, the de-funding of an agency,
Cronauer said that an investigation to determine "what went wrong and who was responsible for such serious breaches in procedure" would be conducted, and that "appropriate corrective action" would be taken.
PWAs to get role in system evaluation
After years of debate, the first steps to develop a system-wide evaluation for AIDS care services funded by Title I and Title II of the Ryan White CARE Act have been set, providing a significant role for the input of recipients of AIDS services.
Earlier evaluation plans have been stymied by opposition from "consumers" of services, who charged that providers were given the dominant role in evaluating their own performance. The controversy reached a boiling point in 1995, when then Philadelphia AIDS Consortium (TPAC) director Jim Littrell released an evaluation plan almost solely dependent on provider input, ignoring a directive from the TPAC board that evaluation was to be consumer-centered.
City and state officials have traditionally defended current AIDS funding allocations on the basis that no objective evaluation mechanism is in place to determine whether current AIDS services are effective.
The new plan, adopted by a joint planning committee of the Philadelphia HIV Commission, which oversees Title I funding, and TPAC, which oversees Title II funding, fully integrates consumer participation in the evaluation process.. It is likely that the same evaluation mechanisms will be used for services supported by other city and state funds as well.
The plan was developed in response to pressure from consumers to make agencies more accountable. It was also developed in response to new guidelines issued by the Health Resources and Services Administration (HRSA), which allocates federal AIDS care funds, requiring that the city take the first steps towards establishing objective standards -- called quality improvement measures -- for each Title I funded service in 1997.
HRSA required that the city establish quality improvement measures for three service categories in the current grant cycle, which ends in March 1997, and that these measures be used to evaluate the quality of Title I funded services in the future.
The city's AIDS Activities Coordinating Office, the HIV Commission and the TPAC board agreed to do joint evaluation of services funded by both Titles I and II, and they designated nutrition, case management, and clinical care as the first three service categories for which standards will be set. AACO hired the AIDS Education and Training Center to coordinate the evaluation process, and the AIDS ETC began the system-wide evaluation by forming an open evaluation committee comprised of consumers and providers of AIDS services from across the region and staff from the three funding groups.
While this plan represents an important milestone in meeting consumer demands for a reliable evaluation process, at the time it was adopted, no specific provisions for consumer participation in setting service standards had been spelled out. This situation was addressed at the third meeting of the evaluation committee in mid-January, when the committee adopted a plan that places consumer input as one of the central features of the evaluation process.
The committee adopted the following model for consumer participation: Quality improvement measures for each service category will be set by individual subcommittees whose members will include front-line service providers or their direct supervisors and consumers. The subcommittees, which will meet in the coming months, will draft the quality improvement measures. These measures and an explanation for why they were recommended will then be reviewed by a committee comprised exclusively of consumers. Project TEACH, the city's only HIV treatment peer education training program, which is a joint project of We The People and Philadelphia FIGHT, has agreed to assist the ETC in conducting consumer training and ensuring quality facilitation of consumer sessions. Only after consumers have given their input independently from providers will the standards be presented to the evaluation committee for approval.
During the evaluation committee meeting where this plan was discussed, reaction to the proposed plan was overwhelmingly favorable. While some committee members did not see the need to establish a separate committee for consumers, other community members and consumers spoke in favor of the plan, and ETC staff members said that they believed that this was the best way to guarantee meaningful participation by consumers. During the same meeting, several committee members stressed the need to include consumers from different racial and ethnic groups and to make sure that the committee develop a strategy to include non-English speaking consumers in setting the quality improvement measures.
In addition to developing quality improvement measures, the ETC is also pursuing other aspects of the system-wide evaluation. They have developed feedback cards that consumers can fill out each time they receive services -- a task the HIV commission staff and the TPAC planning staff promised to do early last year but never completed. The cards ask consumers whether they are satisfied with the services or not, and can be returned to the ETC through the mail or through specially designed boxes located at each provider office. The ETC has begun a pilot program using these cards at several agencies in the area and expects to expand consumer access to the cards in the coming months.
Despite the possible benefits of using feedback cards, ETC staff have said that the kind of information they can gather through these cards is extremely limited. They have pointed out that this is merely the first of many strategies to gather consumer satisfaction data, since many consumers, especially those most dissatisfied with the services they receive, will not even bother to fill out the cards, and in any case the cards only record very limited information. Community members and evaluation experts who have reviewed this pilot project have expressed concern that consumers will confuse the cards with each agency's grievance procedure and that this confusion might inadvertently impede the ability of consumers to actively pursue complaints against specific service providers. The ETC staff have promised to address these issues before expanding the pilot program.
Clinton ups budget for HIV prevention
TB among HIV+ varies by region
There is a higher incidence of tuberculosis among HIV-positive individuals who reside in the eastern U.S. where most PWAs are people of color, according to members of The Pulmonary Complications Of HIV Infection Study Group.
Dr. Norman Markowitz of the Henry Ford Hospital in Detroit and colleagues examined the incidence and predictors of tuberculosis in HIV-positive individuals seen at six urban centers throughout the U.S. More than 1,100 individuals were followed for a median of 53 months, and 31 developed tuberculosis.
The researchers found that location was the most important demographic risk factor. Specifically, the incidence of tuberculosis was higher in the eastern U.S. compared with the midwestern and western regions. Their results also indicated that tuberculosis was higher among HIV-positive patients with CD4 counts of less than 200 cells per microliter and among patients with positive results on purified protein derivative (PPD) tuberculin tests. Subjects with nonreactivity to mumps antigen were also at increased risk for tuberculosis, regardless of their response to the PPD tuberculin test.
The group added that their findings support the CDC's current interpretive criteria for PPD tuberculin tests.
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