Minnesota Department of Health
STD and HIV Section
HIV/STD Community Prevention Planning
COMMISSIONER’S TASK FORCE ON HIV/STD PREVENTION PLANNING
Snelling Office Park
9:00 a.m. - 5:00 p.m.
Thursday, April 15, 2004
Present
TASK FORCE MEMBERS
Gerry Anderson
Kip Beardsley
Kathy Brothen
Donna Clark
Kirk Fiereck
Rhys Fulenwider
Kelly Hansen - Parliamentarian
Doris Johnson
Nick Metcalf
Amy Moser
Steve Moore
Rosemary Thomas
William Grier
Kevin Sitter
Drew Parks
Traci Capesius
Bankole Olatosi
Muhidin Warfa
Cliff Noltee
Wynfred Russell
Charlie Tamble
Becky Clark
Gary Remafedi
Alissa Fountain
COMMUNITY MEMBERS
Fred McCormick
Amber VanderHeyden
MDH STAFF
Ruth Dauffenbach-Kotrba
Luisa Pessoa-Brandão
Julie Hanson Pérez
Lucy Slater
Japhet Nyakundi
Absent
Jerry Moss-notified
Phillip Brown-notified
Roxanne Anderson-notified
Lois Crenshaw
INTRODUCTIONS
Introductions were made. Fred McCormick lit the candle. Amber VanderHeyden read the three
goals of community planning; Kevin Sitter reviewed the meaning of each of the ground rules.
The January minutes were reviewed and approved. The January meeting evaluation
compilation was reviewed. The announcement sheets were passed around.
Task Force Minutes 4/15/04 Page 1
MDH REPORT
Kip Beardsley gave a brief presentation of the 2003 HIV/AIDS surveillance data that was
released yesterday. A more in-depth presentation will be provided to the Task Force in August
or September. The 2003 HIV/AIDS surveillance data can be accessed on the MDH website at
http://www.health.state.mn.us/divs/idepc/diseases/hiv/hivstatistics.html
Kip reported that MDH will receive an approximate $100,000 cut to the federal HIV prevention
budget in 2004. This is a permanent cut that will carry forward into future years. At this time,
the cut will not affect prevention programs or staffing. Prevention programs will probably be
impacted in 2006 when new contracts are developed.
Kip reviewed the Task Force expense and reimbursement policy, which was recently updated.
Members were provided a copy of the policy. There were several major changes: 1) Only Task
Force members are able to claim expense reimbursement; 2) Childcare reimbursement will be
paid at a rate of up to $6.00 per hour per child up to a maximum of $50.00 per day per child;
and 3) Starting July 1, 2004, all members seeking reimbursement of any kind will need to have
an Annual Plan Agreement signed and on file with MDH. New reimbursement forms have been
developed.
Julie Hanson Pérez reminded the Task Force that everyone, including Task Force members
and MDH staff, must RSVP for full Task Force meetings. In the future, food will only be ordered
for persons who RSVP.
Lucy Slater presented a review of the Statewide Planning Process, which was a joint effort
conducted by the Task Force and the Minnesota HIV Services Planning Council (Planning
Council) in 2002. Recommendations were made regarding how to increase participation from
Greater Minnesota in HIV prevention and care planning, and how to improve access to care and
prevention services in Greater Minnesota. The Governmental HIV Administrative Team (GHAT)
is currently in the process of assessing feasibility of the recommendations. MDH does not have
the resources to support regional planning groups as suggested in the recommendations, but
has proposed convening annual statewide meetings in coordination with the Planning Council.
Every third year, regional prevention priorities would be set for Greater Minnesota at these
meetings if the Task Force agrees to prioritize Greater Minnesota as a target population and to
set aside a funding allocation for Greater Minnesota. The discussion regarding Greater
Minnesota as a target population will be held later in the meeting.
PRIORITIZATION OF TARGET POPULATIONS
OVERVIEW OF PRIORITIZATION
Lucy gave an overview of the prioritization process. The primary task of the Task Force is to
develop a comprehensive HIV prevention plan that includes prioritized target populations and a
set of prevention activities/interventions for each target population. Charlie Tamble asked for
clarification in regards to the Task Force’s role in developing the plan. The bylaws state that the
Task Force assists MDH in the development of the plan. Lucy replied that MDH actually writes
the document, but the key components of the plan are based on the work done by the Task
Force.
The plan should focus on a set of target populations that require prevention efforts due to high
rates of HIV infection and high incidence of risk behaviors. The plan paints a picture of
everything that is needed in Minnesota to address HIV, regardless of the funding source.
Task Force Minutes 4/15/04 Page 2
According to the CDC, target populations should be described by HIV status, transmission risk,
race/ethnicity, gender, age, geographic location, and size. The CDC guidance also states that
HIV positive persons will be ranked as the highest priority population. In order to inform the
prioritization process, MDH provides data about HIV incidence, HIV prevalence, rates, and HIV
trends. Task Force members bring knowledge of the needs of the communities they represent.
Task Force members should be able to defend the prioritization process to their communities.
MDH takes the priorities set by the Task Force and uses them to develop a Request for
Proposals (RFP), which results in agencies being funded to implement HIV prevention
interventions in the community.
PROPOSED PRIORITIZATION PROCESS
Julie noted that prioritization of populations is the most difficult work the Task Force does.
Because of limited resources, it is impossible to support activities targeting every population.
The structure of the process itself results in populations being pitted against each other, which is
very uncomfortable. Julie then presented the following process being proposed by MDH for
prioritization of target populations:
Step One
The major target population categories are pre-determined in rank order. The categories are
behaviorally defined and are prescribed by CDC. The rank order is determined by local
epidemiological (epi) data.
Men Who Have Sex with Men (MSM)
High Risk Heterosexuals (HRH)
Injecting Drug Users (IDU)
Step Two
For each major category, a list of subpopulations is identified based on epi data and discussion
with the Task Force. HIV positive persons are the top subpopulation under the MSM and HRH
categories in accordance with the CDC guidance and because they require a qualitatively
different type of intervention.
Step Three
Between August and December 2004, Task Force members (in groups of three) will attend
established community groups and/or convene community forums in order to gather information
from populations at risk about risk behaviors, co-factors, barriers to prevention information and
services, and other (non-MDH funded) prevention resources available in the community.
Step Four
Resource materials are developed by MDH that describe the following for each subpopulation:
HIV incidence, prevalence and trends; size of population; impact of the epidemic; risk behaviors;
co-factors; barriers to prevention information and services; and other resources.
Materials will be sent out to Task Force members prior to the February 2005 prioritization
meeting and members will be expected to review them in preparation for the meeting.
Step Five
At the Task Force prioritization meeting, the Task Force will discuss the information contained in
the materials and ask questions. Members will have the opportunity to provide perspective
based on experience being part of or working with a population, and information learned during
the community groups or forums.
Step Six
Time will be set aside at the February 2005 meeting for Task Force members to complete the
prioritization worksheets.
Task Force Minutes 4/15/04 Page 3
Step Seven
The results of the prioritization process will be calculated at the meeting. The Task Force will
review and discuss the results and come to consensus regarding the prioritization of target
populations.
PROPOSED PROCESS TO DETERMINE SUBPOPULATIONS
Luisa Pessoa-Brendão presented a process to redistribute HIV cases that have an unspecified
transmission category across the other transmission categories (e.g., MSM, IDU, heterosexual
contact, etc.) in order to provide a better estimate of how transmission is occurring within
populations. The process used to redistribute risk among African men and women was different
than that used for other populations because of the extremely high number of cases that have
an unspecified mode of transmission in the African population. (For details of the risk redistribution
process, contact Luisa at 612-676-5596 or [email protected])
Julie then presented a process that would help the Task Force determine which subpopulations
should be included on the list of populations to be prioritized. It is based on a public health
model in which the goal is to prevent the greatest number of new infections with a limited, and
decreasing, amount of funding.
As a starting point, a list of subpopulations under each of the three major categories (MSM,
HRH, and IDU) was developed by race/ethnicity and gender. Based on epi data, objective
criteria were developed to determine the cut-off point for inclusion on the list of subpopulations
to be prioritized. In order to be included, populations must have:
An average of at least 5 new infections a year (over the last 3 years); and
At least 100 living HIV/AIDS cases
Julie then presented some tables showing how this proposed process would impact the
potential list of subpopulations if it were to be implemented at this time. There were a number of
populations of color that would be eliminated from the prioritization list because they did not
have the required number of new infections and living cases.
Julie asked for reactions and recommendations regarding the proposed process, and suggested
that the Task Force consider whether some subpopulations could be combined if the
interventions to reach them would not need to be qualitatively different.
Discussion
There were a number of questions related to the risk redistribution process. In particular, there
were questions about whether it would be possible to use African exposure categories instead
of U.S. categories, and if it is possible to tell whether African individuals were infected before
coming to the United States. Gary Remafedi suggested that travel history could be considered
when trying to determine where a person was infected. Wynfred Russell stated that secondary
migration could also be a factor in determining exposure category. Bankole Olatosi felt that part
of the issue with Africans becoming infected after coming to the United States is because they
think that HIV is only in Africa.
Gary Remafedi stated that he was uncomfortable with the CDC guidance naming HIV positive
persons as the top priority; they should be a priority but not the top priority. He felt that the
focus should be on people before they are infected.
Amy Moser suggested, as part of Step Four of the prioritization process, offering the opportunity
for Task Force members to meet in small groups to discuss the informational materials and ask
questions prior to the Task Force meeting. MDH staff agreed to do this.
Task Force Minutes 4/15/04 Page 4
Nick Metcalf asked how epi data is collected for the Native American population since many
Indians live and receive their health care on the reservations, which are not required to report
HIV cases to the MDH. Rhys Fulenwider added that the specific language in the guidance
regarding tribes must be taken into consideration.
Recommendations were made that the following information also be considered when
developing the list of subpopulations to be prioritized:
- Incidence rate (impact of new infections in relation to the population size)
- Trends (increase or decrease in infections among a population)
- STDs infections
Gary also suggested that prevalence data not be considered in this process. He felt the
prevalence data duplicates the incidence data since new cases are counted among the living
cases. He felt that prevalence data is more important to planning for care than prevention. He
also stated that prevalence data doesn’t reflect changes in mode of transmission, such as
through blood products. Julie noted that prevalence data is important to planning for prevention
services because there is a greater opportunity for transmission among a population that has a
larger number of people living with the disease.
OVERVIEW OF MEETING OBJECTIVES
In order to re-focus the discussion after lunch, Kip presented an overview of the work to be done
at this meeting, noting the critical points where Task Force feedback was needed (in bold).
All Minnesota (approx. 5 million people)
Major Population Categories
Epi and
behavioral
science data
Subpopulations
Data enriched
by community
input
Core Risk Factors
Risk Co-factors
Request
for
Proposals
Intervention
Strategies
Selected
Interventions
Review committee
MDH
Task Force Minutes 4/15/04 Page 5
MAJOR POPULATION CATEGORIES AND TARGET POPULATIONS
GREATER MINNESOTA
Kip asked whether Greater Minnesota should be designated as a major population category or
whether it should be considered as a subpopulation under the behavioral categories of MSM,
HRH and IDU. He noted that if Greater Minnesota were included as a subpopulation, it would
have to be compared to the other subpopulations during the prioritization process. He also
clarified that the decision about whether to have a funding set aside for Greater Minnesota has
not yet been decided. That will happen at a later date.
Discussion
There was quite a bit of discussion with both options receiving some support. Key points of the
discussion follow:
Greater Minnesota should be a separate category because:
The Planning Council has a separate priority for Greater Minnesota, which results in
agencies being funded to provide care services in Greater Minnesota. Since many care
providers are also prevention providers, it might be easier to coordinate care and
prevention under a similar prioritization structure.
Having a separate category for Greater Minnesota would help address the Greater
Minnesota set aside.
Having a separate category for Greater Minnesota would allow regions to identify their
own priorities for targeting their resources, as proposed through the Statewide Planning
recommendations. If Greater Minnesota is included as a subpopulation under the other
categories then the Task Force is making the decision for the regions.
Having a separate category with a funding set aside will ensure that some services are
provided in Greater Minnesota.
Greater Minnesota should be included as a subpopulation under the other categories because:
There is a difference between people injecting in rural communities and those who inject
in the metro area because of the lack of IDU services in Greater Minnesota.
It allows Greater Minnesota providers the opportunity to compete for the same dollars as
all other providers.
Rhys and Kirk Fiereck recommended that Greater Minnesota be a separate category and a
subpopulation under the other categories in order to allow for the possibility of a set aside as
well as the opportunity to compete for funding in the other categories.
Nick called for a count of hands to see how many people wanted:
- Greater Minnesota as a major target population category (the majority);
- Greater Minnesota as a subpopulation under the other major categories (1 person); or
- Do both (1 person).
Consensus: By consensus, the Task Force agreed (with two people stepping aside) to
designate Greater Minnesota as a major population category.
Task Force Minutes 4/15/04 Page 6
YOUTH (AGES 13 – 24)
The discussion then turned to youth. The same question was asked - should youth be
designated as a major population category, as a subpopulation under the other major
categories, or both? Based on epi data for 2003, 90 percent of new infections among youth
were in the metro area. Cases were equally divided between males and females. Most cases
among young males are MSM and most cases among young females are high risk
heterosexual.
Discussion
Amy was inclined to incorporate youth within the different populations but was concerned that
they could fall off the list of subpopulations to be prioritized if the incidence/prevalence wasn’t
high enough to meet the inclusion criteria.
Rhys felt that youth should be a separate category, particularly in communities of color where a
much higher number of young adults are infected. He noted that is was possible that youth of
color are also becoming infected considering AIDS diagnoses at ages under 30, as found in the
Latino male population. He felt that it should be a priority in this process to get information to
youth as early as possible.
Kip stated that it would be possible for the Task Force to decide to include youth as a
subpopulation, regardless of the epi data.
Consensus: The Task Force agreed that Youth All Races would be included as a
subpopulation under the categories of MSM and HRH, regardless of the epi data.
HIV POSITIVE INDIVIDUALS
Should HIV positive individuals be designated as the highest priority major category, or as the
highest priority subpopulation under the MSM and HRH category? Kip suggested that HIV
positive persons would not need to be identified as a subpopulation under IDU because the
interventions to reach them would probably not be different from interventions targeting HIV
negative IDUs.
Discussion
Gary suggested that Prevention for Positives be created as its own category and that MDH be
allowed to figure out how to address the population. Charlie felt that HIV positive persons should
be included as a subpopulation in all the categories because HIV positive persons also interact
with people who are HIV negative.
Consensus: The Task Force agreed that HIV positive persons would be designated as the
highest priority major population category.
MEN WHO HAVE SEX WITH MEN (MSM)
The discussion then turned to how subpopulations would be defined under the major population
categories. The first question was whether subpopulations under MSM should be defined by
race/ethnicity or whether all men of color should be grouped together as one subpopulation.
Discussion
It was suggested that the subpopulations be MSM of All Races and MSM of Color. There was
concern as to whether the same interventions could effectively reach MSM of different
races/ethnicities. Rhys felt that the Task Force should think about how to reach the most people
with the least amount of funding. He also noted that there are similarities across MSM of
various races/ethnicities that cause infection. Nick spoke of the challenges he faced in running
Task Force Minutes 4/15/04 Page 7
an agency that targeted all MSM of color. The clients became predominantly African American,
and other populations began to disengage. There was also a question of credibility since Nick
is not African American. He noted that men of color are a very difficult population to reach.
Consensus: The Task Force agreed that the subpopulations under MSM would be MSM of All
Races and MSM of Color. As decided earlier, Young MSM will also be included on the list of
subpopulations, regardless of epi data.
HIGH RISK HETEROSEXUALS (HRH)
There were two basic questions to be answered in relation to subpopulations for HRH:
1) Should the populations be defined by race/ethnicity or should populations of color be
grouped together? Do various race/ethnicities require qualitatively different interventions?
2) Should men and women be separated or grouped together? Do men and women require
qualitatively different interventions?
Discussion
There were several recommendations made:
Have two subpopulations - HRH of All Races and HRH of Color
Have three subpopulations – HRH All Races, African-born, and Other HRH of Color
Define subpopulations by race/ethnicity
Amy raised the question of consistency in the way the Task Force is defining subpopulations
across major categories. She felt it was very important to be clear about the rationale behind
the group’s decisions so that they can be clearly explained in the future. Rhys stated that
consistency in how subpopulations are defined across major categories is not necessary
because there is no consistency in the epi data between MSM and HRH. They don’t have the
same modes of infection, and don’t have the same risk groups. His understanding of the
purpose of the prioritization process is to identify groups that have the greatest need for
prevention efforts. Under MSM, the reason for identifying MSM of Color as one subpopulation
is because the incidence is high among all MSM of Color. He felt that the Task Force needed to
separately consider where the highest risk is among HRH. He thought it made sense to identify
African born, and probably African Americans also, as subpopulations because of the level of
risk.
Kip noted that the more general the subpopulations are, the less direction is given to the health
department and the other people who use the comprehensive HIV prevention plan. If HRH of
Color is identified as a subpopulation, it does not provide much guidance about which
populations are at the highest risk.
The conversation then turned to whether or not the HRH subpopulations need to be defined by
gender. The Task Force generally agreed that the subpopulations should not be defined by
gender since the risk behaviors of one gender affects the other. Including both men and women
also allows for interventions targeting both partners. Examples were given by Bankole Olatosi
and Wynfred Russell that African men would not go to a prevention program targeting women,
although women would go to a men’s program in order to support them. This was generally
thought to be true across race/ethnicity. It was noted that if subpopulations were defined as
including both men and women, agencies would still be able to propose an intervention to reach
only men or only women.
Consensus: The Task Force agreed that HRH subpopulations will be defined by race/ethnicity,
but not by gender. As decided earlier, Young HRH of All Races will also be included on the list
of subpopulations, regardless of the epi data.
Task Force Minutes 4/15/04 Page 8
INJECTION DRUG USERS (IDU)
Kip asked whether there is a need to look at subpopulations of IDU by race/ethnicity and
gender. Would interventions be qualitatively different by race and gender, or is drug use the
defining factor that should be addressed?
Discussion
Doris Johnson stated that drug use is what drives risk among this population. She didn’t feel
that interventions needed to be different in order to effectively reach men and women of various
races/ethnicities. Rhys agreed. Charlie stated that the only group that he has noticed as having
different needs are MSM/IDU.
Consensus: The Task Force agreed that the IDU subpopulations will be defined as IDU All
Races/All Gender and MSM/IDU.
ADJOURNMENT
The Task Force meeting was adjourned at 4:45 p.m.
Task Force Minutes 4/15/04 Page 9