The MCH team along with various stakeholders identified two priorities pertaining to adolescents during Delaware’s 2020 MCH Title V Five-Year Needs Assessment process.  Delaware selected National Performance Measures (NPM) 8.2, increase physical activity among adolescents 12-17 years of age and NPM 10, increase adolescents who obtain a preventative well visit annually as priorities.  The Title V team chose to select the Adolescent Well-Visit with the goal of incorporating other priorities for this population within the well-visit measure.  We plan to leverage our School Based Health Centers in the state to address priorities like well visit, physical activity, and mental health.

 

Adolescent Well-Visit

 

According to the 2020/2021 National Survey of Children’s Health (NSCH), 28.2% of Delaware adolescents have had no preventive medical visit in the past year.  This percentage has increased over the past few years as the number of Delaware adolescents was 24.3% during the 2019 NSCH.  However, it was highest during the 2018 NSCH when the number of adolescents not receiving a preventive medical visit was 29.8%.  We are aware the COVID-19 pandemic had an effect on adolescents receiving a medical visit; however, we will continue to make this a priority for Delaware.

 

Delaware’s School Based Health Centers (SBHCs) provide prevention-oriented, multi-disciplinary health care to adolescents in their public-school setting, and contribute to better outcomes related to selected priorities, NPM 1 Well Woman Care, NPM 8.2 Physical Activity and NPM 10 Adolescent Well Visit.  There continues to be a growing interest for expansion to elementary, middle, and additional high schools, especially given the recent COVID-19 pandemic.  As we continue to transition out of the pandemic the enrollment and utilization of SBHCs has increased.  School Based Health Centers are going through a paradigm shift, and there continues to be a large number of stakeholder interest and commitment to provide evidence based SBHC services based on national and in state innovations in practices and policies, to enhance the growing number of SBHCs in Delaware within the local healthcare, education, and community landscape.

 

Delaware currently defines SBHCs as health centers, located in or near a school, which use a holistic approach to address a broad range of health and health-related needs of students.  Services may also include preventative care, behavioral & mental healthcare, sexual & reproductive healthcare, nutritional health services, screenings & referrals, health promotion & education, and supportive services.  SBHCs are operated by multi-disciplinary health professionals, which includes a nurse practitioner overseen by a primary care physician, licensed behavioral health provider, and licensed nutritionist.  SBHCs are separate from, but interact with, other school health professionals, including school nurses and school psychologists and counselors.  SBHCs also operate alongside and interact with outside health care professionals and systems.

 

The Delaware Division of Public Health (DPH), in collaboration with several key stakeholders, convened in 2022 and completed the Delaware School-Based Health Center (SBHC) Strategic Plan.  The planning process was utilized to develop a model for expansion of SBHCs that was both financially sustainable and anchored in best practices.  There were 13 goals established to include a comprehensive list of action items to ensure that SBHCs are responsive to the individual needs of Delaware’s children — who, for a variety of reasons, may not otherwise have access to the health care system for critical health and wellness services.

 

The 13 goals of the plan include items, such as creating new SBHC sites where the need is greatest, establishing a new hub-and-spoke model for SBHC setup, fostering partnerships to increase the base menu of services, facilitating referrals to providers, adopting culturally linguistic appropriate services, increasing the capacity for telehealth, developing data collection infrastructure and analysis, establishing payer relationships and funding channels, and more. The plan will be governed by an independent body from public and private sectors, with a completion target date of 2025.  The plan was developed to ensure that SBHCs are responsive to the individual needs of Delaware’s children - who, for a variety of reasons, may not otherwise have access to the health care system for critical health and wellness services.  In June 2021, Delaware released the Implementation Plan for Strategic Plan for School-Based Health Centers.  We will also begin governance and implementation of the Plan as well as setting up a longer-term governance and accountability model to oversee implementation of the Plan and continued success of School Based Health Centers.

 

For the past 30 years, Delaware School Based Health Centers, located in now 33 public high schools and 15 public elementary schools, have contributed to the health of the state’s high school adolescents and have been an essential strategy to support individuals overall physical and mental health.  Eventually, these young women and men will be our health consumers, so it is essential to support health and wellness during this critical period and coming of age.  SBHCs provide at-risk assessment, diagnosis and treatment of minor illness and injury, mental health counseling, nutrition and health counseling and diagnosis and treatment of STIs, HIV testing and counseling and reproductive health services (middle and high school SBHC) with school district approval as well as health education.  Given the level of sexual activity among high school students, persistent high rates of sexually transmitted infections (STIs) and the numbers of unintended pregnancies, reproductive health planning services are very important.

 

In most recent years there have been seven SBHC established in elementary schools with epilogue language from FY2020 expanding SBHCs in elementary schools at two per year in high needs elementary schools throughout the state.  As of this writing, two additional elementary schools are currently going through the process of certification.  Along with establishing SBHC’s in elementary schools many of the SBHC’s are exploring the opportunity of expanding services to more students by opening “spoke” sites.  Having these additional sites will provide critical services to students in our state. In FY2023, two new SBHC were established in high needs elementary schools; Frederick Douglass and Baltz elementary.  As a SBHC they have applied for and are eligible to provide medical, mental health care treatment and health education to promote a healthy lifestyle. These centers will serve children in grades K-5 allowing access to services such as sports physicals, well visits, immunizations, vaccines, and mental health counseling. The SBHC will not replace the primary care provider, it is considered a provider in an integrate network to provide behavioral and physical health services to the adolescents in Delaware.  Addressing or discovering problems before they escalate, connecting children and families to resources in our community, improving health, and reducing long term health care cost are the goals.

 

Mental and Behavioral health services continue to be an area of growth and development.  SBHCs continue to struggle to provide services to students due to staffing shortages and frequent turnover rates.  It is imperative to promote and increase awareness and education regarding resources for Mental and Behavioral health.  Some areas in Delaware experience limited access to healthcare.  It is our goal to increase education, awareness, and resources to young women of reproductive age in the Sussex County area, focusing on the following:

 

Goals	Increase awareness- Educate young women of reproductive age
Target Audience	Young women of reproductive age and pregnant women in Western Sussex Latinx Women in Western Sussex
Key Messaging	Importance of being healthy before and during pregnancies Importance of early prenatal care and where to locate family planning Importance of postpartum

 

In addition, Delaware’s SBHCs provide important access to mental health services and help eliminate barriers to accessing mental health care among adolescents (i.e. women).  Over the last couple of years, school district school boards voted and approved to add Nexplanon as a birth control method offered at 19 of the school-based health center sites.  This is a major accomplishment being that each school district’s elected school board members vote on and approve what services can be offered at each SBHC site.  Offering the most effective birth control methods as an option, gives more young women informed choices so that they can decide when and if to get pregnant and ultimately reduce unplanned pregnancies.

 

MCH previously launched SBHC related information on social media.  We launched phase one and phase two of this plan.  Phase two consisted of informing the public where someone can find a SBHC and promoted enrollment in SBHCs (addressing the how and why with enrollment).  The target audience included parents of elementary-aged children in Delaware.

 

Overall education, awareness, and continued support for adolescents in Delaware is an initiative where Delaware continuously explores avenues to engage the adolescent population.  The goal is to increase avenues to distribute information to adolescents, using methods such as:

 

Social Media	Provider Websites
Bulletin Boards	School Staff
Radio Stations	SBHC Staff
Summits	Community Events
Flyers/Poster	School Events
Student Lead Events

 

To be successful with the adolescent population information needs to be presented in a manner where it is received, accepted, and retrained by adolescents.

 

As adolescents transition into adults, we are working to ensure they have the resources to secure a primary care doctor, transition Medicaid, and to thrive and have a prosperous adulthood.  Community Health workers are assisting to fill gaps with insurance and primary care needs.  Community Health workers educate, provide support, are health promoters, health educators, health advisors, and neighborhood health advisors.

 

In partnership with Planned Parenthood of Delaware, training is offered for staff at School Based Health Centers (SBHCs) each year.  Planned Parenthood attendees range from School of the Deaf, Detention and Treatment Centers from within the Department of Services for Children Youth and Their Families (DSCYF), Delaware Adolescent Program Inc. (DAPI), SBHCs, middle schools, high schools as well as community agencies, partners, and parents.  In addition, mental health and medical providers participate in trainings provided by Planned Parenthood of Delaware throughout the year.  Planned Parenthood of Delaware trains teachers to deliver curriculum to parents and students.  PPHD also has community outreach activities to whose target populations are LGBTQ2S+, pregnant/parenting and juvenile delinquency youth.

 

Supporting LGBTQ+ teens is a growing need throughout the state of Delaware.  Providing awareness, education and support for educators, behavioral health specialist, and medical professionals in the areas of health disparities, Delaware legal protections for LGBTQ+ teens suicide prevention and best practices to for supporting LGBTQ+ teens.  Educators, parents, students, and communities are uniting across race, genders, and place to demand safe and affirming schools where all our students can learn, grow, and thrive.  Planned Parenthood of Delaware has hosted several trainings throughout the year to earn the support our LGBTQ+ teens.

 

Our CDC assignee has been training and building capacity with our Management Analyst in the Bureau of Adolescent & Reproductive Health section to develop performance metrics, data quality audits, and reporting for School-Based Health Centers data submitted by medical sponsors.  Our CDC assignee has also been reviewing YRBS and Delaware School Survey Data to inform surveillance strategies for socio-emotional health of adolescents.  Our SBHC evaluation paper is now under publication.  These data support the use of School Based Wellness Centers as a strategy to increase preventative well-visits, increase physical activity as well as support emotional well-being.  A new SBHC data brief for state fiscal year (SFY) 2019-2020 was developed by linking SBHC enrollment data and Department of Education (DOE) school enrollment data.  An updated analytic evaluation plan linking SBHC enrollment data, DOE school enrollment data, Medicaid claims data, HDD data, with the inclusion of SFY 2021 data (July 1, 2021, through June 30, 2022) is currently underway.

 

Delaware successfully applied and received CDC/Harvard evaluation practicum.  Two students and staff from DPH (Bureau Chief of Adolescent Health, and Management Analyst, Dr. Hussaini) and DOE participated in the practicum during 2022. Dr. Hussaini worked with Bureau Chief of Adolescent Health to mentor the two Harvard students to develop a SBHC elementary evaluation plan.  The program identified efforts to build strong relationships among SBHCs, school personnel, and the community, and ensure that trauma-informed and culturally & linguistically responsive care exist in SBHCs. The evaluation measures enrollment, utilization, and patient; along with intermediate outcome such as referrals to social services, referrals to PCPs, and connections to specialist services.

 

The evaluation consists of two key questions:

1. How do SBHCs in high-need elementary schools operate?

2. How does SBHC-facilitated health care and social services utilization impact the physical and psychosocial needs of students in high-need elementary schools?

 

Interviews and meetings were held with stakeholders to, and the following areas of measurements are also included in the evaluation:

1. Examining whether differing implementation practices between medical sponsors have impacts on quality of care, physical and psychosocial outcomes, and health equity.

2. Assessing current data reporting practices/measures and level of standardization across medical sponsors.

3. Gauging how SBHC systems could anticipate certain health or social needs within these high-need schools.

4. Developing relevant key indicators of health equity in this population.

5. Evaluating successes and barriers to the current implementation of SBHCs, e.g., stakeholder buy-in, communication efforts between SBHCs and other stakeholders, measurement, and data-related issues.

6. Establishing recommendations for each stage of the program which could increase efficiency, quality of care, and healthy outcomes for this population.

 

The logical model and evaluation tool developed during the CDC/Harvard Practicum has not yet been refined for the high-need elementary SBHCs.  Unanticipated increase in supplies resulted in significant delays with construction in one of the related sites.  With state-contracted high need elementary SBHCs in their infancy stages, our focus was on first steps such as building walls, establishing appropriate spaces for provision of care, navigating fiscal nuances, and most importantly, nurturing the partnership between those high-need elementary SBHCs with the schools.  By doing so, the needs of the students can most effectively be met.  Evaluative measures such as those developed by the two CDC/Harvard Practicum students will be woven into the picture of high-need elementary SBHCs eventually and as both sites are seeing patients and have data collected.

 

For our selected prior of increasing the number of adolescents receiving a preventive well-visit annually to support their social, emotional and physical well-being, we have focused on access and availability of mental health resources.

 

We will continue to monitor the mental health status of Delaware’s adolescent population.  We know that COVID-19 had an impact on the emotional well-being of our MCH population, so it is important that we maintain our efforts in this area until we understand magnitude of this issue.  We will continue to partner with our School Based Health Centers to increase the number adolescents who receive an annual preventive medical visit.  Our School Based Health Centers offer mental health support and counseling to support the emotional well-being of adolescents.  School Based Health Centers have also expanded into elementary schools in Delaware as well.

 

We plan to continue our partnership with the Cooperative Extension, University of Delaware, Health & Wellness Ambassadors.  U of D Health Ambassadors are a team of Teen Leaders and Adult Mentors who advocate for a holistic healthy lifestyle across the state.  Health and Wellness Ambassadors are role models and official representatives and promotors who help plan and implement the Delaware 4-H Healthy Living Program aimed at improving the health of themselves, their peers, and their community.

 

We will continue our work with the Department of Education to sponsor a poster contest that promotes teens to seek emotional and mental health treatment, when needed.  We are in discussion what this will look like for the future, whether it is a paper poster contest or a digital media creation.  We are hopeful, we can launch this project during the upcoming grant cycle.

 

We will continue to partner with the Department of Education to advertise Project THRIVE throughout each middle and high school within the State of Delaware.  We will continue to cooperate with participating school districts to promote Project THRIVE and mental health services.  As stated in our Adolescent Health Annual Report, MCH will continue to share the Airtable link with Project THRIVE messaging to our partners so they can easily access and share its contents.  In addition, we plan to continue our working relationship with the various school districts to advertise adolescent health and Project THRIVE, as well as School Based Health Center messaging in each middle and high schools.

 

Physical Activity (ages 12-17)

 

Only 16.0% of Delaware adolescents, ages 12-17, are physically active at least 60 minutes each day, this is compared to the national average of 14.8%.  Delaware’s adolescents who are physically active at least 60 minutes each day, 4-6 days per week, rests at 19.4%, while the national average is 24.1%.  Although, NPM 8.2 is a newly selected priority during this five year grant cycle, MCH has a long history of partnering with the Physical Activity, Nutrition and Obesity prevention (PANO) program In the Health Promotion Disease Prevention Section of DPH.  MCH will continue to leverage this partnership to increase physical activity among adolescents.

 

Physical Activity, Nutrition, and Obesity Program’s (PANO) activities for the Application Year will be focused on key healthy lifestyle and chronic disease intervention areas impacting youth and the families and communities they live in.

 

Through PANO’s Program’s Advancing Healthy Lifestyles (AHL): Chronic Disease, Health Equity & COVID-19 initiative, PANO will continue to support youth health through the AHL foundational pillar: Coordinated School Health and Wellness.  Through AHL, PANO is facilitating the connection between youth-serving organizations (YSOs) and schools to support the health and well-being of youth and to strengthen community partnerships. Under the AHL initiative, these partnerships focus on the link between a community-based, youth-serving organization and the health and social-emotional well-being of participating youth.  PANO will continue to partner with the Boys and Girls Clubs of Delaware (BGC) to implement the Triple Play program in Delaware.  The goal of the program is to improve knowledge of healthy habits, good nutrition, and physical fitness; increase the numbers of hours per day youth participate in physical activities; and strengthen their ability to interact positively with others and engage in healthy relationships.  Triple Play is primarily facilitated by BGC youth mentors (called Wowzers) and college interns, managed by BGC staff.  BGC will implement Triple Play at 9 locations across the state, 3 in each County.  Each 10-week session will run from mid-June 2023 to early June 2024.

 

Through the AHL foundational pillar: Community Capacity Building, PANO will continue to facilitate technical assistance (TA) and implementation support to four community partner teams on the implementation of community-based interventions, all of which impact children and families. PANO has been working with the American Lung Association (ALA), University of Delaware (UD), and Delaware State University (DSU) to provide TA on PANO-related interventions.  All four community partner teams implemented projects in July 2022 which ran through June 2023.  Project implementation will continue from July 2023 to June 2024 and will include an asthma self-management program to be offered to children in schools and/or in youth-serving organizations (YSOs); improving access to healthy, locally produced food in targeted communities; a physical activity and nutrition education intervention for children with disabilities and their families that teaches parents skills to increase the healthfulness of family meals, and increases physical activity for this population; and, revitalizing a community space for health education and physical activity in a summer camp for children in an underserved community.  We will partner with ALA to implement the Open Airways for Schools program which teaches elementary school children ages 8 -11 asthma self-management, and Kickin’ Asthma, a program that empowers youth ages 11-16 to better manage their own asthma in schools during the September 2023 to June 2024 school year.

 

From May 2023 to October 2023, PANO will continue to partner with UD Cooperative Extension to further enhance a Farm to Store pilot project, which supports a relationship between a retail store and a local farm, to provide fresh produce to the community, which includes many children and families.  This program also plans to expand to include a Farm to School component in the Fall of 2023 school year.  Along with our partners, we will continue to provide movement-based and physical activities to youth with disabilities, ages 7 to up to 21 years old in the Caesar Rodney School District.  DSU will also continue to host a Dine and Discover series, in partnership with DSU’s Cooperative Extension program, which offers families healthy eating and nutrition for the whole family.  This program will run September 2023 to June 2024 and plans to again serve Charlton students, with discussions about expanding to Capitol School District students.

 

The team at the DSU Allied Health Center started a community summer program for youth, ages 6 to 12, in the Capitol Park community, a low-income, high-need neighborhood of downtown Dover.  Participating youth will have access to physical activity opportunities and nutrition education, and a community garden during the summer July 2023 to August 2023 season.  This program will be implemented in partnership with various colleges and programs of DSU, as well as other community stakeholders.  One of the goals of this project is to expand after-school programming to serving youth during the September 2023 to June 2023 school year.

 

PANO will partner with other state agencies and community organizations to sustain the AHL foundational pillar of Community Capacity Building.  PANO will engage community partners who are primarily serving disparate or targeted communities, to develop strategies that address PANO related activities. These efforts will enable community-based organizations to achieve long-term and sustainable outcomes around health and wellness initiatives that support young Delawareans and the communities that care for them.  PANO will promote policy, systems, and environmental (PSE) change strategies and interventions through community-based initiatives such as the Advancing Healthy Lifestyles (AHL) Community Mini-Grants and the Lt. Governor’s Challenge.  The AHL Community Mini-Grant program awards grants to communities and organizations that exhibit a strong commitment to tobacco prevention and control programs and are enhancing or expanding access to physical activity and healthy eating opportunities for children, families, and communities.

 

In September 2023, PANO will launch the AHL Community Mini-Grant program for a second year.   The AHL Community Mini-Grants will award funding to schools, community-based, and youth serving organizations that provide physical activity, nutrition promotion and obesity prevention programs or implement PSE changes aligned with PANO’s goals of improving health and reducing chronic conditions.  In the Summer of 2023 PANO will invite community partners to apply for mini-grants in the range of $5,000-$15,000. Awardees must address the AHL outcomes of improving opportunities for physical activity, healthy food, and maintaining a healthy weight by applying a PSE approach.  The 2023 Lt. Governor’s Challenge launched in March 2023 and received 37 nominations by the close of the nomination period, May 31, 2023.  The Lt. Governor’s Challenge Review Committee will review nominee applications through the Summer of 2023 and announce the 2023 winners in the Fall of 2023.

 

PANO will continue to collaborate with the Delaware Department of Education (DOE) on the AHL foundational pillar Coordinated School Health and Wellness initiatives.  PANO will provide funding for the physical fitness assessment and physical education tool, for the 2023 -2024 school year.  We will continue to offer resources for technical assistance for WELNET implementation, professional development, and training opportunities for Delaware educators. PANO will also provide technical assistance and resources to Delaware’s professional Society of Health and Physical Educators (SHAPE DE), which makes up the professional workforce of health, physical activity, and physical education teachers throughout Delaware. SHAPE DE will host its annual convention in October 2023.  The SHAPE DE annual convention is designed to provide SHAPE members and health education professionals the opportunity to share instructional ideas with each other and learn from local and national subject matter experts.  Starting July 2023, PANO will provide event planning, communications, and technical support to SHAPE DE to help build the internal capacity of this non-profit organization that serves as a resource for Delaware health, physical activity, and physical education teachers.

 

PANO will continue to partner with DOE to facilitate improved responses from schools for school health data surveys, including the Youth Risk Behavior Survey (YRBS) and the School Health Profile (SHP).  Select schools are currently scheduling participation in the 2023 Youth Risk Behavior Survey (YRBS) with data collection to occur during the 2023-2024 school year.  DPH is consistently working to improve response rates from the schools, and efforts to find ways to improve school participation will resume.  The School Health Profile (SHP) will be completed in 2024.  The information obtained from the YRBS, and the SHP surveys are used to help develop state programs and initiatives and help to guide prevention efforts, which will improve the health and health outcomes for Delaware communities and youth.

 

PANO will continue to facilitate collaborative work efforts and interventions that address increased physical activity, improved nutrition, and healthier lifestyles for Delaware youth.

 

MCH will continue to support PANO by providing support to the Physical Activity, Nutrition, & Obesity Prevention, Division of Public Health through collaborative efforts to inform maternal and child health stakeholders, other community partners and home visitors about the Advanced Healthy Lifestyle Initiative Webinars on Coordinated School Health & Wellness, Community Capacity Building and Workplace/Employee Wellness.

 

DPH will continue to facilitate collaborative work efforts and interventions that address increased physical activity, mental health awareness, improved nutrition, healthier lifestyles, and information and resources for Delaware children and adolescents.  MCH will continue to utilize DEThrives to engage and inform our adolescent population with up-to-date information pertaining to various needs and topics via social media posts, Facebook Instagram and Twitter.  Subjects pertaining to Adolescents, such as My Life My Plan Teen, Addiction, Mindfulness, COVID-19, School Based Health Centers, Anxiety and Depression, Mental Illness, Exercise, and more have been posted.  In working with our partners, MCH will continue to use social media to promote adolescent health comprehensively.  Social media messages will be developed around the importance of preventative well visits, healthy lifestyles and emotional wellbeing.  We just recently completed the newly designed DEThrives.com website.  Audience pages are recognized under the “Services for Me” page, where content is organized by the user’s life stage.  These life stages include a “Teens” category.  Additional maternal and child health messaging can be found on the different audience pages, which are organized by the different life stages an individual will be in.  All web pages, either a program or audience page, will have a “Related Programs and Services” section at the bottom of the webpage that will list other pages or program pages that relate to the page the user is currently on. This is another way for the user to learn more information about related services DEThrives has.

 

 

Nutrition Counseling

 

New Castle County Community Health Services will continue to expand services in the upcoming year, with the onboarding of the Registered Dietitian Nutritionist (RDN), after the position was vacation during the previous year.  We will continue navigating the Nutrition Program in the direct to accept more patients.  The Nutrition Program will continue making appointments either over the telephone or in person based on patient/parent preference and accommodation.  Consults will continue to focus on the identified nutritional concern(s) and distributing knowledge and resources to help minimize obstacles along the path towards resolution or management of concerns.

 

Being engaged in community health events and conferences throughout the state is critical to broaden the awareness of resources and networks to utilize in expanding nutrition services. New Castle County Community Health Services hosted the Brandywine Lifesavers Event at the Hudson State Service Center in April 2023. Brandywine School District's "Lifesavers" program is designed to create opportunities for all students to experience the healthcare field. As a tour guide, the RDN led a group of students to public health program stations including Sexual Reproductive Health, Child Health/Immunizations, WIC program and the Tuberculosis clinic, along the way introducing the programs as well as the RDN’s role as a public health RDN.

 

In May 2023, the RDN attended the Division of Public Health Physical Activity, Nutrition, and Obesity Prevention (PANO) program’s Inaugural Advancing Lifestyles Conference: Improving Health Through Equity. Conference initiatives included reducing obesity and chronic conditions, achieving health equity by coordinating school health and wellness along with workplace wellness, and fostering connections between youth-serving organizations and schools to support the health and well-being on youth across the state. There were opportunities to engage in panel discussions and network with colleagues as well as other health professionals.

 

Upcoming events our RDN will be attending include the 21st Annual Diabetes Wellness Expo in Dover, hosted by the Delaware Diabetes Coalition (DDC) and sponsored by the Division of Public Health’s (DPH) Diabetes and Heart Disease Prevention and Control Program (DHDPC) and the Physical Activity, Nutrition and Obesity Prevention Program.  This Expo will focus on promoting diabetes self-management and living healthy lifestyle. More than 30 exhibitors and educational seminars will provide information about diabetes management, nutrition, exercise, medication adherence, hearing, and mental health.

 

On National HIV Testing Day, June 27th, 2023, the Community Health Services Registered Dietitian will be attending an event hosted by the Division of Public Health at the Hudson State Service Center for which I will be providing nutrition information tailored for those affected by HIV/AIDS.