Reprinted from the Spring
2004 issue of Village Drum, a publication of the
Community Health Awareness Group (CHAG).
Community Health Awareness Group (CHAG) was successful in securing
three grants last year that have allowed us to embark on an exciting
new journey to reach those at highest risk for HIV. The three grants
are from the Centers for Disease Control and Prevention (CDC), the
Michigan Dept. of Community Health (MDCH), HIV/AIDS Prevention and
Intervention Section (HAPIS) and the Blue Cross and Blue Shield of
Michigan Foundation (BCBSMF).
Combined these grants with synchronous goals are allowing CHAG
to expand our current mobile services to reach individuals at the
highest risk, offer a new rapid HIV test, and provide clients highly
personalized attention from a new prevention case management program.
We can now reach and test more people in locations where risk behaviors
occur, where those engaged in risky behaviors seek help, and/ or
where testing has been ineffective because of poor return rates.
We can provide immediate test results for those who are HIV negative
as well as linkages to needed services. We can offer those testing
positive immediate access to the care system as well as intense one-on-one
risk reduction counseling if they are continuing to engage in risky
Identifying the Need
A key finding of an important study in
Detroit, which CHAG participated in, was that HIV occurs within
the context of various socioeconomic
conditions. “Poverty, discrimination, homelessness, racism,
and low self-esteem…emerged as conditions that created high-risk
environments,” stated the report on the Rapid Assessment Response
and Evaluation (RARE) Study.
These conditions further complicate the
ability to implement interventions effective in creating behavior
change – essential to HIV prevention.
Recent studies of syphilis in Detroit by MDCH indicate that those
who are infected with HIV are still engaging in unprotected sex.
And the Southeastern Michigan HIV/ AIDS Council (SEMHAC) needs assessment
identified a large number of extremely high-risk young men who have
sex with men who were homeless and/or recently incarcerated as well
as other individuals, who in spite of their risky behavior had no
knowledge of appropriate risk reduction strategies.
Seeking out these individuals at highest
risk, providing a rapid test to find out if they are HIV positive
and then assisting them
on a one-on-one basis to help them reduce HIV transmission is a high
priority for the CDC’s Advancing HIV Prevention Initiative
and for CHAG.
Rapid Testing in Outreach Settings
The common component of the CDC grant,
the grant from HAPIS and the BCBSMF grant, is the pilot testing
of the OraQuick™ rapid
test. Contrary to its name this test is not an oral test. It is the
first blood test approved to give either a negative HIV test result
or a preliminary positive test result within 20 minutes. CHAG is
the only community-based organization in Michigan that has been approved
to pilot the HIV Rapid Test in outreach settings.
This test allows CHAG to now go out into
the ‘risk pockets’ that
have been identified in the Detroit area, conduct the test on the
outreach van, or inside a site with adequate facilities, provide
counseling in one session and link clients up with services they
are going to need whether the results are positive or not. For those
with preliminary positive results, a confirmatory OraSure® test
must be done and an appointment scheduled for the client to return
for test results. At that time, a Ryan White Outreach Specialist
arranges a primary care appointment for positive clients and the
STARRS* mobile advocates screen them to determine whether they are
eligible for prevention case management. The clients are also asked
to complete a self-administered survey, which assesses willingness
and ability to engage in the intensive process of risk reduction
The CDC grant provides for staff dedicated
to the new programs and a new outreach van specifically for rapid
testing. The HAPIS
prevention grant is for staff training and technical assistance and
monitoring, which the new test procedure requires. MDCH labs will
continue to perform the confirmatory testing. The BCBSMF grant provided
for Wayne State University (WSU) technical assistance to develop
an effective protocol, and the monitoring and assessment required
for a research model pilot study to find HIV testing and counseling
methods that are more effective at reducing clients’ risk of
Risk Reduction Strategies
The new CHAG prevention case management
(PCM) program – called
STARRS *(Sustained Training in Adopting Risk Reduction Strategies) – is
a highly personalized program to help those HIV infected individuals
who continue to engage in high risk behaviors develop a plan of action
to reduce the likelihood that they will transmit the virus to others.
STARRS then links them to sustained behavior change, such as substance
abuse treatment and mental health services. STARRS also allows confidential
tracking of clients, who all have multiple issues to contend within
their lives, so they don’t fall through the cracks. Services
could include those provided directly by existing CHAG programs as
well as linkages with community services for substance abuse treatment,
mental health and HIV medical care.
An important piece of the STARRS program
is the initial contact with the client and the ability to provide
a rapid test with immediate
results. The STARRS mobile advocates work in tandem with all of CHAG’s
counseling, testing and referral services, as well as all of CHAG’s
Ryan White funded care programs, to identify HIV positive individuals
appropriate for prevention case management.
STARRS is based on sound behavioral research
with input from consumers and technical assistance from experts.
CHAG has worked with its active
Consumer Advisory Group to make sure the needs of consumers have
been addressed in developing the new PCM program. CHAG staff also
works closely with advisors from WSU. An important part of the new
program is a tracking system developed by WSU using a unique identifier,
a special formula of a client’s personal information that is
known to them but that does not reveal their identity, to ensure
that there is follow-up within CHAG’s various programs and
also with collaborating agencies. It also involves obtaining consent
for follow-up with newly diagnosed individuals who have been screened
for STARRS but are not ready to accept services at the time of diagnosis,
and allows for identifying clients in outreach settings who have
dropped out of the system. Many fail-safes are built into the program
for quality assurance and there are strict guidelines for measuring
outcomes. There are many reasons why CHAG is well suited to provide
optimal PCM services. One is that many of the individuals testing
positive for HIV have substance abuse issues that need to be addressed.
Not only is the Life Points syringe exchange van a resource for active
injection drug users, CHAG’s Point of Change substance abuse
program provides a full range of services including immediate access
to substance abuse treatment.
After an eligibility screening for the
STARRS program and a referral to CHAG’s Ryan White funded case management program to address
the food, shelter, clothing and medical needs of the client, the
STARRS client is ready to be assessed for risk behaviors and the
development of a risk reduction plan. STARRS involves weekly face-to-face
individual counseling as well as peer-led group work based on the
client’s current level or readiness for behavior change. CHAG
has cross-program collaboration and holds case conferences to assure
a client’s needs are being met. Clients are reassessed at 3-month
intervals. Once goals are met for STARRS, clients will remain in
Ryan White case management as appropriate. Collaboration has always
been a key to CHAG’s success in our mission to provide health
care to African Americans in the City of Detroit. This synchronicity
of funding and prevention programs now allows us to do that for those
most in need of our services.