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They’re labor-intensive and costly, but prevention projects in North Carolina show that clinicians and public health officials can reach people most at risk for HIV if they go directly to their street corners, colleges, gay nightclubs, homes, neighborhoods, and shelters. These programs work well partly because they offer additional health services at-risk people, including blood pressure screenings, screening for other sexually transmitted diseases (STDs), and referrals for housing and health care.
Here are how the North Carolina prevention and testing programs work:
• Bring HIV prevention services to those most at risk. In Asheville, NC, a nurse practitioner visits a local homeless shelter to provide HIV testing and counseling, as well as STD prevention and referrals for other health problems, says Marti Eisenberg Nicolaysen, a nontraditional counseling, testing, and referral sites coordinator and public health advisor with the Atlanta-based Centers for Disease Control and Prevention. Nicolaysen is assigned to the state of North Carolina STD Prevention and Care Branch in Raleigh. "There is a comprehensive program that reaches homeless adults who have risk behaviors," Nicolaysen adds.
CDC statistics show that the greater Asheville area has had an exploding HIV epidemic. For example, there was an increase of 60% in the AIDS case rate in Asheville and surrounding areas between 1991 and 1997. This is compared to an AIDS case rate increase of 43% in large metropolitan areas during the same time period. Also, the HIV infection rate nationwide is three times higher in the homeless population, and 69% of homeless adults are engaged in HIV risk behaviors.
The Greensboro area brings prevention services to a housing authority community center, churches, homeless shelters, jails, drug treatment facilities, and even to street corners, says Caroline Moseley, MEd, CHES, health education manager at the Guilford County Department of Public Health in Greensboro. "We go into the communities on a regular basis, pass out condoms and information, make referrals to whatever people need, and also provide HIV and syphilis testing," Moseley explains. "It’s labor-intensive, but we really are reaching the people we need to reach."
While the health department’s clinic is easy to access in a location near downtown, the majority of people who come into the clinic are what Moseley calls the "well worried."
"These are people who don’t know a whole lot about HIV and aren’t engaging in very high-risk behaviors," Moseley says. "Those at high risk are not accessing traditional health care services at all, unless they end up sick in the hospital."
In Rocky Mount in eastern North Carolina, one prevention project uses a mobile area health clinic van to reach minority women of childbearing age and their partners. The van has also visited neighborhoods, trailer parks, and emergency evacuation areas where there has been flooding. A nurse visits target communities and offers counseling, women’s health screenings, blood pressure screening, risk assessment, and HIV and syphilis testing and referrals. Sometimes the van has provided screening for tuberculosis infection, glucose monitoring, pregnancy tests, and even minor dental work, Nicolaysen says.
The additional health services were the result of the program’s collaboration with an agency called Down East Partnership for Children, which provides children with dental screening and immunizations. "They also do outreach and distribute fliers to make sure people know when the van is coming to their area," Nicolaysen says. "It’s been very successful."
• Provide follow-up with results and counseling. Outreach workers will return to the same sites where they provided testing and counseling to give follow-up information and treatment to those who need it, Moseley says. "We’ll bring back results to people on the street, and if treatment is needed, we’ll transport them to a hospital," Moseley says. It’s difficult sometimes to find the people who were tested in these community locations, but it can be done, she says. For example, in one quarter this year, the program tested 441 people, finding three who were positive for HIV, and outreach workers provided follow-up post-test counseling to 163 people, Moseley says.
"The CDC is pushing to have more people get their results, even if they are negative, but that’s hard to do with this population because they’re very transient," Moseley adds. "They may be tested and then end up in someone else’s county, and we don’t see them for six months."
The post-test counseling session focuses on reminding clients of a risk reduction plan and will discuss whether they will need a follow-up HIV test, depending on when they last might have been exposed to the virus. These sessions may last 20 minutes at a community setting or about 10 minutes when conducted on a street corner. "Our counselors are skilled at asking questions and getting clients to think very quickly about their risks," Moseley says. "I’m a firm believer that the kind of prevention that works is one-on-one intensive counseling."
• Use a multidisciplinary team. A typical street corner outreach session in Greensboro may take an entire afternoon. It will be conducted by a team consisting of health department employees and professionals from community-based organizations (CBOs). The team often will have a health educator, a phlebotomist, a social worker, a peer counselor from an AIDS service organization, an addict in recovery from a local drug treatment center, nurses, and others, Moseley says. "It’s important that our outreach team is well-versed in community services, even though our primary agenda is to prevent HIV and help people find out their status," Moseley explains. "But a lot of times HIV is not the clients’ agenda, and they may need housing or food first."
So the multidisciplinary team’s first concern is to provide clients with the services and help they need. "We’ve had clients who knew we were there to test them for HIV, but they most needed shelter," Moseley says. "So we hooked them up with a shelter, which also is one of our testing sites, and then two months later when they came back to that shelter, they were ready to be tested."
• Obtain joint funding and support. North Carolina started the outreach prevention programs and has obtained support and/or funding from the CDC, the Guilford Community AIDS Partnership, People Stopping Syphilis Today, the North Carolina Syphilis Elimination Project, and other organizations. "We started out funding HIV prevention service delivery because we were in an emergency mode and someone had to do something," Moseley says.
Since 1997, the CDC has been involved. Currently there are nine projects (costing $475,000) that use state and CDC money, including projects formed by six community-based organizations and three local health departments, Nicolaysen says.
"We fund them to have these community sites offer HIV and STD prevention and testing, STD expanded services, and how they do it is up to them," Nicolaysen says.
• Promote special events. The Guilford County Department of Public Health in North Carolina has a strong relationship with CBOs, which help to sponsor special events where HIV education and testing may be provided. For example, the health department and CBOs have provided HIV/syphilis testing events, sickle cell anemia screenings, and HIV testing at gay/ lesbian bars. They’ve also held HIV educational events at area colleges and have provided neighborhoods with special health screenings, including blood pressure checks. They may even bring health and HIV services to local motels where migrant populations might be found.
"People may not come in just for HIV testing, so that’s why we attach lots of services," Nicolaysen says. "The collaboration with community agencies is very important."