2014 APA Gold Achievement Award: A Pioneer of Integrated Mental Health and Substance Abuse Services for the LGBTQ and HIV Communities

In 1984, the AIDS epidemic was ravaging the gay community of San Francisco, and it became increasingly clear that mental health and psychosocial issues were a critical part of AIDS care. The AIDS Health Project (AHP) was started in March 1984 to address these needs as well as the homophobia and AIDS phobia that existed within the system of care and within the broader community; to help people coping with the death that was rampant in the early days of the epidemic; and to nurture dignity, compassion, and emotional and psychological health in the socially stigmatized groups and affected communities. AHP, a division of the University of California San Francisco (UCSF) Department of Psychiatry at San Francisco General Hospital, developed one of the country’s first systems of mental health care for people with HIV/AIDS. Since its founding, AHP, now known as the Alliance Health Project, has been a pioneering advocate for integrated, culturally competent services. The mental health consequences of the AIDS epidemic have been considerable, affecting not only people who have become infected or ill, but also those at risk of infection and those whose friends and loved ones have become ill and died.

Originally established to support the emotional and psychological health and well-being of the largely gay and bisexual men then most affected by the HIV epidemic, AHP expanded its mission in 2010 to serve the lesbian, gay, bisexual, transgender, and queer (LGBTQ) communities. In its 30 years of service, this community-based program has provided HIV prevention, education, counseling, and psychiatric services to tens of thousands of HIV-infected men, women, and youths and their providers. In addition, AHP has pioneered a variety of programs that have become models of care within the city and throughout the country.

In recognition of its array of innovative programs to support the HIV and LGBTQ and HIV-affected communities, the UCSF Alliance Health Project was selected to receive APA’s 2014 Gold Achievement Award in the category of academically or institutionally sponsored programs. A detailed description of the program is available in an online supplement. The award was presented October 30, 2014, at the opening session of the Institute on Psychiatric Services in San Francisco.

Early years and the San Francisco model of care

The UCSF Department of Psychiatry at the San Francisco General Hospital established this community-based program at a time when some hospital staff feared going into wards where AIDS patients were being treated. The founders of AHP knew the epidemic was taking its toll on the community, not only through loss of life but also through the emotional stress of dealing with loss and fear in a stigmatized population. AHP’s early work involved providing clinical services to individuals living with HIV/AIDS who struggled with mental health issues and psychiatric disorders. AHP also provided education and HIV risk reduction counseling to individuals at risk of becoming infected with HIV. With this comprehensive approach to services, AHP was a pioneer in developing culturally competent, integrated care. In fact, this approach strongly reflected the values of the San Francisco model of care, which emphasizes treating patients with compassion and respect, providing an array of health and social services, and collaborating closely with the San Francisco Department of Public Health and local community organizations, with the goal of maintaining clients in the community as much as possible and deemphasizing hospital-based care.

An early example of how AHP responds to community need is AHP’s development in 1985 of an HIV counseling and testing protocol, which later became a national model. AHP leaders felt strongly that face-to-face counseling offered individuals the best chance of learning how to protect themselves and others from infection. This approach reflected the mental health orientation that the agency brings to HIV/AIDS treatment and was consistent with the principles AHP applied within existing group support programs: that successful HIV prevention counseling requires discussion of an individual’s personal fears and circumstances. This model went into operation in June 1985 and became the prototype widely used throughout the United States and abroad for two decades.

Centralized services for the LGBTQ community

AHP has long been committed to the emotional and psychological health and well-being of the LGBTQ community, especially people living with chronic mental disorders. As a long marginalized group in the United States, the LGBTQ community faces unique challenges and stigma that have created obstacles to accessing health care. AHP offers LGBTQ‐affirming mental health services, substance use counseling, and peer support to individuals, couples, and groups to counteract these stressors. Located close to the Castro, the well-known home of the city’s LGBTQ community, AHP is San Francisco’s primary LGBTQ mental health clinic, now serving some 6,000 people annually. The vast majority of clients survive on low incomes—86% on incomes of ≤$20,000 per year and 78% living on ≤$15,000 per year—and are underinsured. All client services are free of charge, including HIV testing and screening for sexually transmitted diseases, individual and group psychotherapy services, and ongoing psychiatric clinical care, including medication evaluation and monitoring and case management. In addition, a mobile team brings HIV testing and screening for sexually transmitted diseases to clients who might otherwise not be tested.

Thanks to foundation, corporate, and individual supporters, in 1997 AHP was able to secure over $1 million of in-kind and donated services to renovate what was an antiquated and poorly designed building into a modern 14,800-square-foot mental health services center. The center now has seven support group rooms, 15 individual counseling rooms, two conference rooms, and a large training room. In addition, there are nine single-occupant staff offices and nine shared staff offices. The services center features a modest décor with offices furnished as comfortable, therapeutic environments. The facility is in compliance with the requirements of the federal Americans with Disabilities Act, complete with an elevator and wheelchair-accessible restrooms, conference rooms, and spaces for meeting with clients.

Innovative services that work: sharing the San Francisco model of care

In 2002, James W. Dilley, M.D., the executive director of AHP, led a California Endowment–funded systematic analysis of the mental health system’s support to the HIV community in San Francisco and developed recommendations for improving care. Particular focus was on identifying groups of clients who demonstrated unmet need, especially need that resulted in high-cost public services and individual suffering. A main finding of this analysis was that AHP’s client base was increasing in complexity, with significant prevalence of individuals with triple diagnoses (HIV, mental illness, and a substance use disorder). With these findings, AHP successfully applied for federal funding to develop three innovative programs in response to these needs. Each of these programs helped make elements of the San Francisco model of care known across the nation.

Assertive case management

First, AHP sought to assist homeless people with HIV, a population that has been shown to be high utilizers of high‐cost, high‐acuity care in the public health system. Many also struggle with mental illness, a substance use disorder, or both. With funding from the federal Center for Substance Abuse Treatment (CSAT), AHP developed an assertive case management (ACM) model to serve these clients. AHP helps these clients by stabilizing their complex housing, medical, and mental health needs by proactively responding to potential problems before they reach a crisis point. Program evaluation data have demonstrated that homeless clients receiving ACM decreased their use of general emergency and psychiatric emergency services compared with their utilization prior to receiving ACM; they also achieved longer periods of stable housing and showed improved adherence to antiretroviral drug regimens at six and 12 months postintervention. With this evidence, similar programs have been implemented throughout the country.

AIDS and Substance Abuse Program Plus

The second innovative AHP program to become a national model is the AIDS and Substance Abuse Program (ASAP) Plus. This program provides a supportive environment to people of color who are at risk of HIV or who have HIV and are seeking to address the impact of substance abuse. ASAP Plus offers individual substance abuse counseling, integrated mental health services, and group support services. This program incorporates several evidence‐based practices, including motivational interviewing and a harm reduction approach to promote the health and wellness of clients. From 2009 to 2013, ASAP Plus was funded by another federal CSAT grant. The program is continuing with support from other sources, including the San Francisco Department of Public Health. AHP also has recently become eligible to receive Medi‐Cal funding for ASAP Plus services.

Through ASAP Plus, AHP learned more about how to best help clients in its service population. The program adapted and evolved to include specific focus on housing, primary medical care, and psychiatric medication management, all provided at the AHP Services Center. The colocation of psychiatric, case management, substance use, and HIV prevention services helps ASAP Plus clients facing a complex constellation of health and life challenges to build more stable lives. ASAP Plus staff members provide intensive support to clients managing the stress of the housing process, which often puts pressure on clients’ ability to maintain their abstinence from substance use. Using motivational interviewing techniques to build a relationship with clients helps staff to lay the foundation for helping clients work toward and then maintain abstinence from alcohol and other substances, improve their mental health, and address their health and housing needs. In January 2014, AHP submitted an ASAP Plus Program Guide to CSAT for distribution to other agencies as they implement similar programs.

Personalized cognitive counseling

The third AHP program that has become a national model is personalized cognitive counseling (PCC), a single-session counseling approach to HIV risk reduction for gay and bisexual men who are repeat testers for HIV. By the mid-1980s, AHP program data showed that many gay and bisexual men who were counseled and tested for HIV were getting tested multiple times. Although they received prevention counseling each time, they were continuing to engage in high‐risk sexual behavior. Data on seroconversion showed that the rate of new HIV infection among these repeat testers was almost three times that of men who had not received multiple HIV tests. AHP staff recognized the need to use a different counseling approach with the repeat testers. PCC was developed on the basis of a five‐year study at the AHP Services Center, where hundreds of gay and bisexual men requested an HIV test and opted to participate in the study. This form of counseling focuses on the self‐justifications (thoughts, attitudes, and beliefs) a person uses when deciding whether to engage in high‐risk sexual behavior. The 30‐ to 50‐minute PCC intervention is conducted as a component of the counseling, testing, and referral service for gay and bisexual men who meet the screening criteria.

In 2010 the Centers for Disease Control and Prevention (CDC) endorsed PCC as one of the few effective behavioral interventions targeting gay and bisexual men. PCC has been adapted for use in health departments and community‐based organizations around the country and is being disseminated nationally by the CDC. Under contract with the CDC, AHP’s publications and training program will develop online training to supplement nationwide in‐person PCC training over the next three years.

Measuring outcomes for continuous improvement

Over its 30‐year history, AHP has honed a commitment to program evaluation and quality improvement. For example, ASAP Plus outcomes were measured through the use of a Substance Abuse and Mental Health Services Administration survey. The Government Performance and Results Act survey asks ASAP Plus clients about substance use and mental health symptoms, such as depression and anxiety, and inquires about housing and employment. Follow-up data indicate that clients show sustained improvement in abstinence from alcohol and illegal drugs and in housing stability, employment, and depression and anxiety. From 2009 to 2013, the survey was administered by AHP staff at intake with follow-up six months after intake if the client could be located and gave consent to be surveyed. The staff made a concerted effort to locate as many clients as possible and interviewed 213 of the 272 ASAP Plus clients, for a six‐month follow‐up rate of 78%. This is a considerable achievement considering the highly mobile nature of the target population.

Every AHP program is based on a contract with goals and objectives related to that service, the population to be served, and the number of service hours to be delivered. Client data collection and analysis, annual client satisfaction surveys, and the use of behavioral and psychological rating scales are standard operating procedure. One example of recent results related to clients’ self-reported experience of the services they receive at AHP includes a 2014 survey of 245 clients. In response to the question “Overall, how satisfied have you been with the services you’ve received at AHP today?” >98% (241 of 245) of clients felt either very satisfied (86%) or somewhat satisfied (13%). Clients continue to feel that the services they receive help them with the problems they sought to address. Of the 162 clients who responded to the question “Have the services you’ve received helped you deal more effectively with your concerns or problems?” 98% responded that they helped “a great deal” (67%) or “somewhat” (31%). Clients reported overwhelmingly that they would recommend AHP to another person seeking services. Of the 159 respondents, 98% (156 of 159) said they were very likely (83%) or somewhat likely (15%) to do so. Such endorsement is particularly relevant because it demonstrates a client’s trust in AHP, which extends to the client’s support system.

Program managers regularly review performance data and assess the progress of a program toward its milestones and objectives. Performance results are reported to the staff and to the agency director. This information is used to identify areas of concern and develop strategies to address them through program adjustments. In 2013, AHP held two focus groups with clients, family, and community members to request feedback on services. In addition, since 1986 a Community Advisory Board—composed of clients, mental health professionals, and AHP and LGBTQ allies—has advocated for the community and serves as a sounding board for agency ideas and initiatives.

Funding

As a nonprofit organization operating within the School of Medicine at UCSF, AHP receives no program funding from the university and instead relies on a combination of grants and contributions from corporations, private foundations, government contracts, and individual donors. The program has been able to leverage the value of monetary donations by consolidating the administrative tasks of many programs into one administrative group located at the AHP Services Center. Of $8.5 million in revenues for fiscal year 2013, $7.9 million was funded by government contracts. AHP is currently unable to take private-pay clients, but AHP leaders are hopeful that this will change.

Outcomes and future directions

AHP has been serving the HIV and LGBTQ communities for 30 years. Its work has evolved as understanding and treatment of HIV/AIDS have progressed, with AHP always searching for ways to serve the unmet mental health needs of the community. More than 200,000 individuals have been treated, and more than 80,000 health care professionals, educators, and students have been trained. The PCC intervention, for example, is in use at more than 50 sites throughout the United States. AHP has published extensively and provided training for others around the world, and the program has established itself as a leader in the treatment of HIV/AIDS. The program has been strongly based in academia, at UCSF, but directs its services to the LGBTQ and HIV-affected communities.

Looking ahead, AHP envisions addressing health disparities affecting LGBTQ people through direct service and research to further understand the impact of stigma on these communities. Today, AHP seeks funding to support expanded behavioral health and wellness services for the LGBTQ and HIV-affected communities because unmet client demand and AHP’s belief in the efficacy of community psychiatry demonstrate that these services are needed. The March 2011 Institute of Medicine report The Health of LGBT People is part of the increasing acknowledgment, at a national level, that LGBTQ individuals are ill served by status quo medical care. With this expansion, AHP is once again innovating—this time in service of LGBTQ mental health, substance use, and HIV prevention services.

For more information, contact James W. Dilley, M.D., Alliance Health Project (e-mail: [email protected]).