HIV/AIDS organizations undertake major initiative to re-evaluate delivery of services

Major changes may be underway for three of the Boston area's leading HIV/AIDS service organizations. Last week AIDS Action Committee (AAC), JRI Health and Cambridge Cares About AIDS (CCAA) sent a letter to other organizations serving people impacted by the epidemic informing them of the beginning of an initiative to study the possibility of cooperation and strategic partnerships between the three organizations to improve their efficiency and their delivery of services to consumers.

The three organizations are working with the Boston Foundation, which has contracted the consulting firm New Sector Alliance to study the organizations and the possibilities for collaboration. Among the possibilities on the table are collaborations and partnerships in certain program areas, mergers, and, on the opposite end of the spectrum, continuing on without any additional collaboration.

"I don't think anyone is attached to any other outcome other than how we can build a more sustainable service delivery system for people living with and at risk for HIV," said Douglas Brooks, executive director of JRI Health.

He said one of the questions New Sector Alliance would investigate is whether there are overlapping services the organizations provide that could be consolidated to improve efficiency and reduce costs.

Brooks said the strategic initiative between the three groups follows years of conversations among colleagues within the field about the structural challenges facing the state's AIDS service delivery system. Millions of dollars have been lost from state funding for HIV/AIDS programs since the massive budget cuts that began in 2002, and funding from foundations and private donors has also become increasingly scarce over the past several years, yet each year brings a steady stream of newly infected people in need of services. Brooks said that while AIDS service organizations have not yet reached a crisis point, major changes are necessary to ensure that these organizations and the services they provide are sustainable over the long term.

"Unless we have some consolidation of work, of efforts, I don't think the system as it currently exists is sustainable. There's just not the money for it. And we're having to look at, as we consider health disparities and healthcare disparities and the various populations affected by and infected with HIV, there are a broader range of services we need to offer with fewer dollars," said Brooks. "And coming together to develop a strategy among ourselves in conjunction with private foundations, corporations, government and other institutions, benefits us and benefits our ability to do the work we need to do in a sustainable manner."

Rebecca Haag, executive director of AAC, said the three organizations would solicit the opinions of stakeholders throughout the initiative. From February through early May New Sector Alliance will analyze the three organizations - including the services they provide, their finances, their core competencies, and other aspects of the organizations - and lay out different possibilities for collaboration. Over the course of this process Haag said the organizations would consult with consumers, staff, funders and others impacted by their work.

"We're just at the very beginning. We're like anyone else, this is a transparent process. We've just sent out notification to all of our stakeholders in the last 24 hours," said Haag, speaking with Bay Windows on Feb. 20.

John Gatto, executive director of CCAA, said like many AIDS service organizations CCAA has been feeling the pinch in the current economic downturn. State budget cuts last October meant the loss of one of their state counseling and testing contracts; Gatto said the organization was forced to let one employee go, although they were able to absorb most of the impact of that cut without having to reduce their counseling and testing work substantially. He said the number of responses to CCAA's annual appeal is lower than in past years, and people are donating less. Yet he said CCAA remains in a financially strong position, and he said the three organizations are discussing collaboration from a place of strength. The troubled economy, Gatto said, did not prompt them to begin these discussions but it made them more urgent.

"I feel we're in the best place we can be, and these partnership discussions don't come from a place of weakness. ... Many organizations are talking like this now, many organizations have been talking like this for a long time, but people haven't stepped up to the table in the way they are now," said Gatto. "So this isn't something that comes out of nowhere."

Gatto said the three organizations would look at ways to pool resources to reduce overhead and other administrative costs, but they will also be looking more in depth at whether the state's HIV service delivery system needs an overhaul. He said the state's AIDS service organizations formed in the early days of the epidemic when AIDS was an immediate public health crisis, but with the advent of life-saving medications HIV/AIDS has morphed for many people into a chronic illness. Gatto said the needs of people living with HIV/AIDS are much different than they were two decades ago.

"Part of the issue is that for many of the people we serve the issues of poverty, homelessness, substance use, mental health are more acute than either their HIV or HIV risk," said Gatto. "There are other disease-specific models and disease-specific services, so I think we have to look at HIV in a different sort of way, to look at it as a chronic disease and supporting people in the long term. And the expertise of AIDS organizations, what does it need to be now that the epidemic has changed, and what should our role be, in terms of who we're serving and what we're trying to do?"

Reactions to the three organizations' initiative was generally positive, although Stephen Batchelder, a member of the Massachusetts Statewide Consumer Advisory Board (CAB), said he hopes the organizations take seriously their commitment to include consumers in their decision-making process. The Statewide CAB advises the state Department of Public Health (DPH) on HIV/AIDS policy issues, and Batchelder, a resident of Southeast Massachusetts, has served on the CAB for about five years. Batchelder said in recent years some HIV/AIDS organizations have made major changes to their programming without seeking consumer input, although he declined to single out those organizations by name. He also said if the organizations decide to cut costs by consolidating certain overlapping services underneath one organization he worries that the consumers who previously accessed those services at other organizations may not be willing to make the switch.

"I'd be curious to see if they have a prioritization process of what services are going to be most important, which ones they're going to keep, who's going to do what. They all have their strengths and seem to serve different populations, and I'm not sure if everyone with HIV/AIDS is going to be comfortable at the same place," said Batchelder.

Kevin Cranston, director of DPH's Bureau of Infectious Disease, said the harsh reality of decreased funding for HIV/AIDS services means that agencies may have to become more specialized and eliminate duplicative services. He said organizations are increasingly competing with each other for the same shrinking pot of funds, and he said executive directors and board members of state AIDS service organizations have told him they are having increasing difficulty putting together the funding needed to maintain the current level of services.

"This is hard because as much as we want to preserve maximum choice for people with HIV and people at risk ... I think we have to face some hard realities, largely driven by economics, that we may not be able to provide everything at every agency," said Cranston.

There are some existing models for successful collaborations within the HIV/AIDS field undertaken to reduce costs and ensure that programs remain sustainable. Cranston pointed to Pathways to Wellness, the South End-based acupuncture and holistic medicine treatment center that has made treating people living with HIV/AIDS a cornerstone of its work. Pathways originally provided services in its own freestanding clinic, but in 2007 the organization moved into South End Community Health Center. The organization remained autonomous, but moving into the health center allowed them to maintain sustainability in the face of decreased state funding. Cranston said the move was a net gain for both organizations, allowing Pathways to continue to provide services while expanding the range of services available to patients at South End Community Health Center.

Without innovative collaborations Cranston worries that the state's AIDS service organizations will meet the fate of some of their counterparts in other states. He has heard recent reports of organizations in Atlanta, in South Carolina and on the West Coast that either closed suddenly or that are on the verge of closing.

"I don't want that to be the model, where an agency announces one day that it's closing its doors," said Cranston.

Allison Bauer, the Boston Foundation's senior program officer for health and human service programs, also said there are other models for collaboration and restructuring that could prove useful to HIV/AIDS organizations working to adapt to funding challenges. She pointed to the efforts by Boston's Community Servings and other AIDS food-bank programs across the country, which found that as people were living longer and as funding for AIDS programs became scarce it became impossible to sustain their programs. Community Servings and similar programs across the country broadened their mission to serve people suffering from a range of medical conditions, and that expanded mission made it possible for them to continue their work.

"They saw food as medicine. It's not just about AIDS, it's about cancer and about other illnesses," said Bauer.

Boston Foundation's support for the three organization's initiative is part of a larger mission by the foundation to promote collaborations and strategic partnerships among Bay State non-profits. Last year the foundation released a report on the state of Massachusetts's non-profit sector, and one of the key recommendations was for agencies to form partnerships to eliminate redundant services and reduce administrative costs. Bauer said if AAC, JRI Health and CCAA succeed in forming an effective partnership, they could serve as a powerful example to other non-profits throughout the state. She said many non-profits worry that forming partnerships or merging with other organizations will be seen as a sign of weakness or failure.

"It's not that, oh gosh, they're merging because they're financially weak. These are financially strong organizations that in fact, the reason they're strong is they have smart managers and are making smart managerial decisions," said Bauer.

HIV/AIDS organizations in other cities have also been looking at strategic partnerships to respond to financial challenges, but not without difficulty. Marjorie Hill, executive director of Gay Men's Health Crisis (GMHC) in New York City, said she knows of at least two major strategic partnerships between AIDS service organizations in New York that came together over the last two years, one between an AIDS service organization in Harlem and a struggling syringe exchange program and another between an HIV/AIDS food program and a home healthcare program. But she said she has heard that the negotiations behind the former partnership were tense, despite the fact that both organizations wanted to form a partnership.

Hill saw firsthand how much tension could arise around discussions of strategic partnerships and mergers. She said recently another AIDS service organization approached GMHC to begin a conversation about a potential partnership. But when Hill went to meet with them she said they suddenly seemed resistant to discussing the terms of a partnership.

"Two weeks later at the meeting, everyone at the meeting was nervous and looked at me like I was ready to kidnap a young child," said Hill. "I had to say that I had not initiated it. And so it made me just a little bit wary of those conversations. But we would welcome it. We think looking at ways of streamlining overhead and sharing resources is a good thing, and we applaud AIDS Action Committee and the other two organizations for doing it."

Brooks acknowledged that discussions about partnerships between AIDS service organizations can be nerve-wracking for people in the community, and he said the three organizations were committed to making the process as open as possible.

"The three of us having these conversations can be unsettling for some folks - what does this mean? Are they trying to create one large institution? And we really are being transparent in what we've put out to the public in creating an inclusive process," Brooks said.