HIV/AIDS funding is in a state of crisis — or so anyone might deduce upon surveying the situation in 2003. Federal Ryan White CARE Act funds continue to be slashed (three of the four titles were cut this year, the first time since the CARE Act was established in 1990); 13 states currently have enrollment caps for the AIDS Drug Assistance Program (ADAP), which provides free or low cost AIDS medications to persons living with HIV or AIDS; and nine states have ADAP waiting lists (three people died in West Virginia this year while awaiting access to the life saving drugs). HIV programs at the Centers for Disease Control and Prevention (CDC) and the Minority HIV/AIDS Initiative were flat funded by both the House and Senate, while prevention programs that operate outside the Bush administration’s “abstinence only” model continue to be subject to government audits. Meanwhile, the word from Washington is not to expect any increase in federal HIV/AIDS funding — at least until the CARE Act is reauthorized in 2005.

Closer to home, in August the HIV Planning Council (responsible for allocating CARE Act funds to services in San Diego County) grappled for days to make up for a $540,000 shortfall in the state budget. In the process, the council cut $150,000 from food services, while The Center’s benefits counseling program was completely de-funded.

Though Gov.-elect Arnold Schwarzenegger has at times portrayed himself as moderate on GLBT issues, his choice to head the audit of California’s $99 billion budget, Donna Arduin (former budget director for Florida Gov. Jeb Bush), has a record of supporting cuts to health and human services programs. While HIV/AIDS advocates will be asking the governor to locate an additional $40-50 million in funding for ADAP and to maintain other services at their current funding levels, the prospect looks bleak.

Terry Cunningham, chief of the San Diego County Office of AIDS Coordination, said that the California Office of AIDS and other state agencies were recently assigned a mandatory exercise in which they were to cut 20 percent of their entire budgets (presumably in preparation for Schwarzenegger’s impending axe).

“We’re sitting in very dire times in California — especially with the budget crisis,” said Cunningham, who noted that the state just took a 15 percent cut to prevention two years ago. Though hopeful, Cunningham said he’s not taking stock in any measure of grace being afforded to the state AIDS budget by the Schwarzenegger administration. He said he fears the CARE Act could ultimately be relegated to a block grant system, with the state taking as much as 10 percent off the top for administrative costs before allocations are made to eligible metropolitan areas, with San Francisco and Los Angeles taking priority.

The Center currently receives close to 48 percent of its budget from CARE Act funds (as opposed to 60 to 80 percent in previous years). “I think The Center is very concerned with shrinking resources, expanding need and how we’re going to make certain the people who are getting the services are the people who genuinely do not have other resources and are the most needy of those services,” said Delores Jacobs, The Center’s executive director.

“The cuts in funding and the reality that things aren’t going to get better any time soon certainly move us to look to be more efficient in how we’re providing our services,” added Alberto Cortes, executive director of Mama’s Kitchen, a meal delivery service for people living with AIDS. “Maybe somewhere down the road we’ll need to reexamine the level of service that’s provided.”

Shannon Wagner, executive director of Being Alive San Diego, said the organization has also been affected by funding cuts. “We had to cut back a great deal on the staffing,” she said. “We had to tighten up on all of the regular expenses — from office supplies to walking around and making sure every light’s turned off. It’s become increasingly difficult to provide the services for the little bit of money that’s available. Some of the things are just going to be eliminated altogether.”

As an example, Wagner noted that the planning council voted in August to de-fund respite services.

“They are going to wipe it out and put that money into primary medical and dental care,” said Wagner. “The only healthcare or hospice pool that will be open is from the Council of Community Clinics, and it’s going to be $25,000 for the year — and that’s to administer it, to hire somebody to set the appointments, everything. It means very few people will be served and will be able to get that care.”

“Since the first federal resources were made available to state and local health agencies for AIDS prevention in 1985, federal [HIV/AIDS] funding … has skyrocketed to $13 billion for fiscal year 2003. As a result of the work of highly mobilized lobbying forces, more is spent per patient on AIDS than on any other disease, though it does not even currently rank among the top 15 causes of death in the United States.” Thus states a 2001 report from the Citizens Against Government Waste (CAGW), a private, nonprofit organization in Washington, D.C., that monitors government spending. “Even though they get far less research money,” the report continued, “in 1996 heart disease killed 24 times more and cancer killed 17 times more than the number of people who died from AIDS.”

The report goes on to denounce perceived abuses in AIDS funding, citing some blatant examples, such as the Tampa Hillsborough Action Plan in Florida, which the report said used HOPWA (Housing Opportunities for People With AIDS) funds to “lavish its executives with SUVs that come with $45,000 maintenance accounts, and tickets to professional sporting events.” The CAGW report further noted federal AIDS funds used for “shopping sprees to Neiman Marcus and calls to psychic hotlines” by a Texas AIDS agency, as well as $21.8 million to house homeless people with AIDS that went unspent in Los Angeles (which could have provided antiretroviral therapy to people on ADAP waiting lists for two years, the report said).

Denounced by a majority of GLBT and AIDS activists as biased and/or homophobic, CAGW’s underlying contention was that while some 1,100 people across the country remained on waiting lists for ADAP (that number has since dropped to just over 600), duplication of services and a wasteful utilization of prevention funds had become rampant. On the latter account, several GLBT activists said that the report presented a valid argument.

HIV/AIDS educators maintain that in order to reach the target population greatest impacted by the disease — men who have sex with men — education and prevention programs must speak the language of that population. However, in a climate of decreasing funds and increasing need, some of the programs the CAGW report cited as dubious continue to raise questions for people on both sides of the issue. On its web site, CAGW cited federal funding expenditures close to $9 billion domestically for HIV/AIDS prevention and treatment initiatives in 2002, estimating that $1 billion of total domestic AIDS spending in 2003 would fund duplicative or questionable programs.

As an example of questionable prevention spending, CAGW noted a June 13 warning letter issued by the CDC to San Francisco’s Stop AIDS Project. The letter referenced the organization’s workshops discussing oral sex and how to have “safe and friendly relations” with male prostitutes, ordering the organization to cease the programs or risk losing up to $500,000 a year in federal grants.

The CAGW report went on to cite more examples of what it portrayed as gratuitously salacious HIV prevention programs, including one AIDS nonprofit receiving $1 million a year in CDC funds that hosted a workshop on how to have anal sex while suffering from diarrhea. AID Atlanta, Inc., which received more than $3.5 million from the government in 2000, sponsored a workshop for gay and bisexual African-American men that included such topics as “tossing salad” (rimming) and “strollin’ in the park, through the trails.”

Last year, syndicated columnist Dan Savage, founder of Gay City of Seattle, a nonprofit organization created to address AIDS health and prevention issues, said he had distanced himself from the organization he founded because the group was “primarily concerned with gay men’s social lives, not their health.”

This summer, CAGW cited a study published in the June issue of the Journal of Acquired Immune Deficiency Syndrome, in which Professor David Holtgrave said that failure to reduce new HIV infections in the U.S. by 50 percent in the next two years could cost the nation more than $18 billion by 2010. CAGW and other prevention critics seem to imply that because the level of new HIV infections in the U.S. has remained constant at around 40,000 per year, U.S. HIV prevention efforts must be failing.

But who’s to say that new infection rates wouldn’t have risen to 100,000 per year without the aid of such efforts, argues Cunningham. Though much has been learned in the past few years, Cunningham said measuring the efficacy of prevention programs can be difficult due to the random nature of prevention funding — a “pot of money” doled out here and there for prevention programs with no real continuity to establish a solid baseline of data. To the conservative mantra, “How can you tell me it’s working?” Cunningham replied with exasperation, “How can you tell me it’s not?”

As a result of the increased scrutiny of HIV prevention programs, AIDS researchers this year received word that their grants could be in jeopardy if they include trigger words such as “gay,” “men who have sex with men” or “anal sex.” Though the CDC has long mandated that AIDS funds not be used to promote sexual activity, the degree of scrutiny in this area has reportedly reached a fever pitch under the Bush Administration.

According to Cunningham, slightly less than $3 million from the state Office of AIDS is dedicated to prevention and education in San Diego County each year. While local HIV prevention workers are funded to do some prevention outreach in local bathhouses, overall education programs have been decidedly tamer in San Diego. “You have to tailor the message to make it so that it’s acceptable in San Diego County,” said Cunningham. “Whereas prevention messages can be more explicit in a subway in New York City, they have to be milder in San Diego County, because of the atmosphere.”

One program that could potentially come under scrutiny is a retreat for HIV-positive people, held twice a year by Bienestar. Ricardo Gallego, a prevention case manager at Bienestar, said the retreats are intended to “create consciousness in people of re-infection, the use of condoms and to reveal the HIV status of partners.”

While the government continues to look towards inspection of prevention methods to assure HIV/AIDS funds are more equitably distributed, ADAP representatives are looking at drug manufacturers for relief. ADAP reps from California, Florida, Maryland, Massachusetts, New Jersey, New York, North Carolina and Texas have been negotiating with drug manufacturers this year to discuss easing budget shortfalls currently faced by state ADAP programs. Though the ADAP reps were able to negotiate $65 million in yearly pricing concessions for antiretrovirals supplied through ADAPs, in order to alleviate restrictions on ADAP funding for fiscal year 2004, policy experts estimate that an additional $283 million will be needed.

Meanwhile, as ADAP funds continue to be strained (About 26,000 Californians alone rely on ADAP for their medications), Roche’s Fuzeon debuted this year at a whopping $20,000 annually, roughly three times the cost of other AIDS drugs.

Perhaps the current level of scrutiny surrounding HIV/AIDS funding can be traced back to 2001. Some five years after the introduction of antiretroviral drugs had dramatically increased the life expectancy, and, to some degree, quality of life for people living with HIV/AIDS, questions began to arise about just when people living with the disease could be expected to return to work. After all, many living with the disease appeared much healthier and were presumably enjoying leisurely, stress-free lives.

Though many PWAs continue to exist at or near the federal poverty level, a subclass of those living with HV/AIDS had seemed to emerge. Dubbed the “disability queens” in an October, 2001POZ magazine article, some PWAs and people with HIV were being dissed for “riding the disability gravy train into the fast-lane lifestyle.”

The POZ article and others like it, including a cover story appearing in the August, 2001, issue of the Gay and Lesbian Times, noted examples such as 51-year-old Robin Lambert, who POZ said spent his days at the gym and nights out clubbing while bringing in $70,000 a year — all while not having to work.

Then as now, the quandary faced by those on disability with HIV or AIDS is the fear that by returning to work they could potentially lose their health benefits, becoming ill again later down the road. In addition, the often-harsh side affects of AIDS medications have left some in a tenuous condition that prevents them from holding down 9 to 5 jobs.

In the POZ article, Martin Delaney, founding director of the San Francisco-based Project Inform, an AIDS treatment and advocacy center, conveyed outrage at people taking advantage of the system. “There are plenty of people who either never warranted disability in the first place or warranted it for a time but should have come off when the new therapies came along,” Delaney told POZ. “You see guys with 800 T cells and healthy as could be. Under what justification are they receiving disability?”

Though those with cancer and heart ailments are typically taken off disability when they begin to show signs of recovery, in California, those with HIV or AIDS are considered disabled when their T cell count drops below 200. Though it may rise considerably, their status isn’t subject to reevaluation and they remain eligible for benefits such as Supplemental Security Income (SSI), Social Security Disability Income (SSDI) and/or Medi-Cal.

One reason people see the face of seemingly well-off, white gay males living with the disease more often could be the fact that those receiving benefits tend to the more urban and informed segment of the population.

“Can somebody skunk the system?” Cunningham posed. “Yeah, they could. I think that we’re probably in the high 90s in the percent of people that are eligible for services that get them. There’s [probably] a very small percentage — two, three, five — that are able to work the system. Any system that you get, there’s going to be somebody that figures out a way to get around it — and people do, but I think that with the diminishing amounts of money that we’re getting, we’re being more cognizant of it….

“Can I say that every dime that goes out the door is used for the purpose that it’s supposed to?” Cunningham asked. “I can’t say that with 100 percent accuracy. But I can say it with 95 percent accuracy.”

In response to questions on the subject of potential fraud within the CARE Act funding system, HRSA was not initially forthcoming. Kevin Ropp, a spokesperson for HRSA’s office of communications, eventually gave San Diego County a positive review in regards to its accountability with CARE Act funds. “HRSA receives allegations of the misuse of CARE Act funds infrequently — about one per month nationally,” Ropp responded. “This is because most issues surface and are resolved at the grantee level. HRSA intervention is generally not required.

“HRSA has received no formal complaints of abuse from San Diego or California in the past year,” Ropp continued. “When HRSA does receive an allegation, we take it seriously and investigate. If a problem is identified, we work closely with the grantee to correct the issue as rapidly as possible at the local level….

“The Grantee is responsible for correcting provider wrongdoing or, if necessary, ceasing to fund those providers who do not or cannot comply with contractual agreements. Serious breeches are usually reported to HRSA project officers.”

“In the end, it’s the grantee (the county) who’s responsible,” Cunningham concurred. “We have to make guarantees to the feds that we’re going to use the funding properly. And I think we’ve been very good stewards of the money. We get a lot of grief from the community for being as stringent as we are.”

For the past two years, the Employment Support Project (ESP) has offered those living with HIV/AIDS in San Diego an opportunity to re-enter the workforce. People are usually referred to the HOPWA-funded program through their case managers.

ESP’s Autumn Doermann said that on average, out of the 30 people they see each month, seven to 10 will find employment, typically starting out on a part-time basis. The concerns of PWAs re-entering the work force have remained about the same, she said. “They haven’t worked in five years, so their skills are either out of date or they’re worried about filling out an application and putting that they haven’t worked for five or 10 years.

“A lot of people that come in are fearful of losing their benefits if they go back to work,” added Doermann. “If you’re on SSI, less than $800 a month is what you receive. If you go back to work part-time, they take money from you and so people are worried, ‘Well, if I get a job and I’m making too much money and I lose all my SSI, what’s going to happen if I get sick? Will I even be able to pay rent?’”

Among its primary function, the San Diego County Office of AIDS Coordination is charged with assuring that title I and II CARE Act funds (which provide roughly $10.5 million in medical care to uninsured people living with HIV/AIDS in San Diego County) are utilized as the so-called ‘payer of last resort,’ available to only the neediest of the needy.

Eligibility for all CARE Act funded services through the county is an HIV-positive diagnosis, with certain services requiring an income level of $1,100 a month or less (with $650 added for each additional qualifying family member). Cunningham said there has been talk for the past few years of lowering the $1,100 income level requirement by $100-200.

Services currently subject to the income level requirement include: emergency housing assistance, food services, transportation, emergency financial assistance, legal services and respite/emergency help. Services with no income eligibility requirement include coordinated service centers, integrated services for women, children and families, treatment education/adherence and drug and alcohol treatment.

Though not subject to an income eligibility requirement at present, starting in March of 2004, complementary therapies will be subject to the $1,100 per month income level requirement.

Under the heading of complimentary therapies, The Center’s Holistic AIDS Response Program (HARP) offers acupuncture, chiropractic, homeopathy, hypnotherapy, massage, nutritional counseling, reiki, tai chi and yoga (among other programs), to support the healing process of persons with HIV/AIDS.

Until one week prior to press time, The Center’s web site noted that HARP also offered “astrological counseling, energy healing, healing touch, therapeutic touch, music therapy, phoenix rising, sound therapy, spiritual mind treatment, tarot, transformative magic, feng shui and psychic reading.”

“We do hypnotherapy for some pain management but haven’t done the rest in more than a year or 18 months,” Jacobs explained. Though even the remaining services may sound extravagant, volunteers administer each service, said Jacobs. From CARE Act funding, The Center then pays a full time HARP coordinator and part-time outreach coordinator to recruit volunteers. Though the current amount allotted to complimentary therapies is $100,000 per year, Jacobs noted that this will be decreased to $70,000 next March (an amount that also covers rental on the space, supplies and liability insurance). According to the City of San Diego’s web site, HARP will receive an additional $98,095 in block grant funding for fiscal year 2004.

“We had recommended cutting out complementary therapies altogether,” said Cunningham. “Their demographics were showing that they were servicing mostly people who lived in central San Diego and they weren’t good at getting the service out to all parts of San Diego.”

Though many had anticipated cuts to the AIDS Drug Assistance Program this year, the funding was left untouched. However, a co-payment was added for those whose federal adjusted gross income is between 400 percent of federal poverty level (roughly $34,000 in 2000) and $50,000. To be eligible for ADAP funding in California, one must be HIV-positive, have an annual federal adjusted gross income below $50,000, not be covered by or eligible for Medi-Cal or another third-party payer, be a resident of at least 18-years-of-age, and have a valid prescription from a California licensed physician.

“More than 80 percent of our clients make less than 200 percent of the federal poverty level,” said state ADAP Program Coordinator Trish Salveson, “so there’s a very small population that would fall into that category of having an ADAP co-payment.”

Asked what the Office of AIDS was doing to prevent abuses to the ADAP system, Salveson said, “We have some pretty extensive eligibility guidelines for all of our eligibility enrollment workers at our local enrollment sites…. All of those enrollment workers go through a training program and become certified prior to being able to do ADAP enrollment. We’re looking at actually requiring that they re-certify every year, so that they’re up on the latest training….

“We also have program coordinators in the Office of AIDS that go out and visit the local enrollment sites,” Salveson added. “With 260 enrollment sites and four of us, it’s done on a priority basis, with the larger sites … taking precedence. And that’s the point at which we actually review client charts to assure that the documentation proving that a client is eligible for the program are in those client files.”

According to Wagner, Being Alive was asked to require additional documentation this year from those seeking the agency’s services. “As of July 1 of this year, we had to have documentation and proof,” said Wagner. “And we had to follow up afterwards and check with the offices and make sure that it really was a diagnosis letter…. We used to just get a letter of diagnosis from the person’s doctor. We would have them sign a release and verify their income.

“There were some people floating around with fake letters of diagnosis,” Wagner added. “They had actually gotten somebody else’s letter of diagnosis and blanked out all the fields and made copies of it, so that they could fill in their own name and information and try and access services when they really didn’t have a diagnosis…. It was going on kind of everywhere. With the documentation and the verification … that’s stopped.”

According to Cunningham, under the terms of their contract with the county, Being Alive should have been asking for the additional documentation all along. “We have had to hold them to the scope of work of their contract, which includes eligibility that they had not been doing previously,” he said. “We noticed on their [monthly progress] reports that they had not met their goals. At approximately the same time Shannon came in asking for more money for the program. We met with them and ascertained that they were not doing the task as outlined in the scope of work.”

According to Cortes, Mama’s Kitchen receives 21-22 percent of its funding from the CARE Act. Under the terms of a new contract with the county, Cortes said the organization is also requesting more documentation. The new contract includes income and health eligibility criteria for services that were not previously required, said Cunningham.

“The documentation requirement has changed,” said Cortes. “We basically have requested that the HIV diagnosis be certified. In the past the case managers would speak on behalf of the clients requesting services, and their form would indicate what the HIV status was. Ryan White contract requirements have changed and they’re asking us to have actual documentation proving the diagnosis, so now people need to submit medical proof of their diagnosis….

“In addition to that they need to provide documentation of their income. In the past it used to be that the case manager would just tell us what their income was.”

Auntie Helen’s, a local nonprofit that provides laundry service for some 350 people living with AIDS, saw its CARE Act funding reduced from $60,000 to $30,000, before being cut off completely two years ago. The CARE Act de-funding was the result of a fuss made by former Republican Congressmember Tom Coburn, who noted with outrage that AIDS patients were receiving free laundry service. A man who has publicly stated his belief that “homosexuality is morally wrong,” Coburn currently heads President Bush’s AIDS Advisory Council as his oft-cited “abstinence man.”

“We sort of became the whipping boy there,” said Bob Stanley, executive director of Auntie Helen’s. “We were told that we could no longer access the funds, which, in some ways, was a blessing in disguise. Being part of that Ryan White thing was like making a deal with the devil. You had to jump through a lot of hoops — the accounting, the questions they were asking. Just to keep track of the paperwork we had to hire people and we ended up spending almost as much money on it as we were making. The different audits that are required and the number of different meetings … were really taking away form the mission of the organization.”

In addition to the laundry service, Auntie Helen’s runs a thrift store, which maintains a list of about 1,500 clients eligible for free clothing. Profits from the thrift shop and private donations helped to make up for the loss of CARE Act funds, said Stanley.

Auntie Helen’s also receives $6,280 a month through a block grant with the city of San Diego. According to the city of San Diego’s web site, in Fiscal year 2004, that amount will be reduced to about $20,000.

Asked about eligibility for services, Stanley said, “By and large our clients are pretty destitute…. We mainly serve a lot of people of color (about 47 percent). You have to have HIV to access our services, although if somebody comes in here and they said they lost everything in the fire, we’ve been giving them clothing.”

The eligibility to receive laundry service is more restrictive, Stanley said. “By and large it’s for people who are sick or in the last stages of AIDS…. I go by what the case manager thinks. They sort of separate the sheep from the goats, because in any kind of service like this you always run into people who are trying to take advantage of the system.”

Stanley said there had been some trying to access the laundry service that weren’t eligible for it. “A lot of times the case manager just doesn’t have time to screen everybody real well.”

With the de-funding of The Center’s benefits counseling contract, both case managers and peer advocates at local AIDS agencies will have to take up the slack in helping people with HIV/AIDS navigate the often mind-numbing governmental system of obtaining benefits.

“I believe the county of San Diego is going to offer benefits counseling training to case managers and peer advocates so that people can continue to get that service,” said Jacobs. “There’s a real question about whether the case managers and the peer advocates will, one, have the time and, two, have the specific expertise…. It’s a little bit of a maze to try and understand. In some of the programs missing one filing deadline or one co-payment means you’re dropped from the program. People are going to have to take more personal responsibility for understanding [the system] than they have had to in the past.”

“Most people that come in have no money… are homeless, are getting evicted, or they just got fired because their employer found out they had HIV and they’re being subject to some kind of discrimination,” said benefits counselor Carmen McDonald-Goldberg. “We’re helping them figure out what they can get.”

In essence, case managers bear much of the responsibility for making sure a client is eligible for the services they are receiving. According to Cunningham, case managers are mandated to do an eligibility assessment of a client every 120 days.

“I think that’s a misperception that people are trying to navigate [the system],” McDonald-Goldberg said. “Certainly if someone seems to be trying to use the system or lie, we would not enable that. We would just tell them what they are entitled to…. A lot of newly diagnosed people — even people that have had HIV for 10 years — have no idea they could have had help paying for their medications. No one ever told them. Things like that happen all the time.”

Bob Lewis, director of HIV services for Family Health Centers of San Diego, said case managers with the Gay Men’s Health Clinic typically re-verify a client’s information every 90 to 120 days.

“The eligibility scale for case management is very diverse,” said Lewis, who noted that the clinic’s case managers see about 400 people per month. “It takes into account housing status, income, primary language and [other factors]. A total scoring determines if someone’s eligible for case management or not. For people who aren’t eligible for case management, we, as well as most of the other (county) funded programs, have a peer advocacy program — people who are familiar with the system of HIV services in San Diego who are willing to help people navigate it…. In our case, the peer advocates are in the next office.”

According to Cunningham, evaluating which services require funding, and at what levels, is an ongoing and arduous process. “People feel as though if you take something away, they’re never going to get it again,” he said.

As an example, Cunningham noted the case of food vouchers, which the county discontinued. “[Food vouchers] came about because of the collapse of the AIDS Foundation,” Cunningham explained. “We needed something overnight to take the place of the food bank at the foundation and we decided to go with vouchers…. We even stamped them with no alcohol and no cigarettes to be purchased with these foods. But, there was no guarantee that somebody wouldn’t get those vouchers and turn around and sell them…. You really weren’t supposed to, but a lot of cashiers just looked the other way. People knew what markets were more apt to give you the cash back. We really couldn’t control the usage of them and we certainly couldn’t connect the usage of the food vouchers to improved health outcomes – and the big one these days is [showing] improved health outcomes.”

Asked about the paper trail that shows HRSA proof of improved health outcomes for CARE Act funded programs, Cunningham said, “We have an auditing unit in the county that actually goes out once a year and checks people’s books…. The feds have told us that we can take up to five percent of the total grant award in order to create this quality assurance, quality management procedure that does the books and audits the books.”

“They pretty rigidly enforce [the requirements],” said Stan Lewis, manager of HIV/AIDS services for Neighborhood House Association, which is funded by the Minority AIDS Initiative and serves roughly 75 percent African-Americans and 25 percent Hispanics. “We get visits from the county looking for paperwork and we have to make sure everything is up to date. Otherwise you can lose your contract pretty quickly.”

However, Lewis noted that there is no absolute certainly in the information he and other agencies may provide the county.

“If a client tells us they’re taking their medication, we have no way of knowing if they are or not,” said Lewis. “We take their word for it…. Some of them refuse to take their meds for various reasons, but that’s not our decision to make. If the client says they’re taking their medication 100 percent of the time, we report that, even though I think it’s a fallacy, because nobody takes their medication 100 percent of the time.

“But the county has this rule that says so much percentage of your clients should report their taking their medication 100 percent of the time,” added Lewis. “So some of the goals might not very realistic – especially with the hardcore clients we see. I think more than 90 percent of our clients are living on SSI; it’s a real poor clientele. For a lot of those coming to us for services, I think their HIV diagnosis is secondary to the economic necessities that they’re missing. They come because they can get hooked up to housing and food. By providing those services, we try to get them to go into treatment for their HIV, and, more importantly, get them hooked into prevention.”

Though working with populations where the disease continues to spread rapidly, Lewis said Neighborhood House organization has no funds for prevention itself.

“We’re not even funded for condoms,” said Lewis. “We beg for condoms from other agencies that have funds and who help us out…. It seems ridiculous to me that every agency would not have some funds for prevention.”