Collaboration saves some resources
Until recently, a typical state model for providing HIV services has been to delegate prevention and testing programs to one group of experts, serving on a separate board from the experts who are overseeing HIV treatment and care programs. While many states still adhere to this model, there’s a new trend in which state health departments are encouraging the two groups to collaborate and even merge boards. The goal is to increase efficiencies, save board members’ time, and improve communication between the two camps.
"When the epidemic first happened in the early 1980s, prevention and care grew separately," says Chris Aldridge, MSW, HIV prevention and care program specialist with the National Alliance of State and Territorial AIDS Directors (NASTAD) in Washington, DC. "But with highly active antiretroviral therapy (HAART), people are living longer and have a better quality of life, and what has happened is that prevention and care have grown closer together. Some of their goals are more in common now." So it makes more sense for the people involved in prevention planning and care planning to collaborate, he adds.
One good example of this collaboration can be found in Michigan, where prevention and care processes recently have been merged, Aldridge notes. "At the end of this year, Michigan will have one single statewide group that works on prevention and care planning." Other states that have moved toward collaboration of prevention and care include Nebraska and Utah, he says.
Here’s a brief look at what these three states have done to change their prevention and care planning:
• Michigan. The state has a regional configuration for HIV care and prevention that has been in place for several years, says Liisa Randall, PhD, prevention consultant for Southeastern Michigan Health Association in Okemos. In 1994 when the Centers for Disease Control and Prevention (CDC) first released guidance on community planning, state officials met with community health agencies, AIDS service organizations, and other nongovernmental organizations (NGOs) to discuss HIV services, she says. "We asked them, What is the best way to safely enact guidelines, and how do we address Ryan White requirements?’" Randall says. "They said, Get this as local as possible, but don’t go nuts and make it an administrative nightmare.’"
Since Michigan has 83 counties, it seemed to be a good idea to avoid having a planning group in each county, so the state began taking a regional approach to providing HIV care and prevention. At first the state had parallel processes for prevention and care with groups representing each aspect. State bodies, representing each, brought together the regional groups, she says. "About 18 months into the planning process, there were a number of community folks who said, This is a little bit crazy.’"
Most of Michigan is rural, and many of the group members from rural areas already were serving dual purposes by sitting on boards for both prevention and care services. Plus an AIDS Policy Commission formed through legislation advised the state to look into consolidating planning processes. "We convened the Too-Many-Meetings meeting," Randall says. In less than three days in 1997, representatives from prevention and care regional groups, state officials, and others met and came to an agreement that separating prevention and care planning required too many meetings and wasted human and other resources. So HIV state officials met with prevention and care partners to discuss collaboration and how the two processes could be brought together.
Through this process, state officials discovered that the two factions had different definitions for some words, such as the word "outreach." To prevention people, outreach had to do with field-based, community-based education programs. To people working in HIV care, the word outreach referred to early intervention services for HIV-positive patients. "Folks had some fears, and some of those fears were difficult to get past," Randall says. "One of the biggest fears was that when prevention and care merged, one of them would get all of the money." However, this fear was unfounded because the money dispersed to each remains separate, she notes.
After several years of answering concerns and working toward collaboration, the care and prevention planners began to trust each other, Randall says. Now the collaboration is producing positive outcomes in terms of joint activities and events, and the two groups have a much better understanding of how the other one works, she adds.
"The most important thing is that our planning partners have embraced the notion of primary prevention for HIV-infected individuals, and they want us to understand how to do that," Randall says. "By the same token, clinicians are now beginning to understand how to integrate prevention into clinical services." For instance, now clinicians realize that if they are seeing patients on a long-term basis it makes sense to do prevention services, and clinicians are educated about community resources to which they can refer patients.
"We are also holding one-and-two-hour workshops with a little skills building for physicians and medical students," she says. "These are little things, but penetrating the provider community in that way is a challenge because of issues with time, resources, and interest."
Through these educational efforts, state health officials have learned that physicians are uncomfortable discussing gay sexuality. So a medical provider education project, SCRUBS, was launched for doctors, physician assistants, and others: Gay and lesbian speakers discuss AIDS, health care, and sexuality, Randall says. "Providers who went through the SCRUBS program say they are much more comfortable and much more confident discussing gay sex."
In 2000, the merger was complete with the two state bodies becoming one group that deals with both prevention and care. A next step will be to facilitate local links between prevention and care services, Randall says. "Those serving HIV-infected individuals will spend two days in the spring working with case managers, disease intervention specialists, and partner counseling and referral folks to talk about how to better move individuals to prevention and care and other supportive services," she explains. "They’ll discuss how we help them and identify their needs and help them get to a place that’s appropriate for their needs."
The consortium approach
• Nebraska. Since the state has a low incidence of HIV infection, but is a large state geographically, there long has been a trend of HIV planners doubling up, says Sandra Klocke, BSN, MS, administrator of the HIV Prevention & Ryan White Title II program in Lincoln. "When we had regional collaboration for planning and treatment, the same people were doing both. The rural areas elected to merge prevention and treatment in 1999."
At the same time, there were six regional groups but no statewide group, and as state officials tried to build capacity and skills in the six regional groups, the task proved frustrating, Klocke recalls. "We decided we needed to merge them together into one group, and now there are six regional advisory groups. When we merged the six groups into one, it made sense to merge care and prevention," she adds. Thus, the new Nebraska HIV Care and Prevention Consortium was born.
"One of the challenges this year is how to develop a comprehensive care that includes care and prevention," Klocke adds. At focus groups that included people living with HIV/AIDS, planners asked what kinds of services were needed and whether they needed more representation, she says. This information, added to surveys and paid research, provides state officials with an idea of how to make HIV services as meaningful as possible and which services are needed in the state.
The merged consortium is becoming very cohesive and is advocating for the state’s HIV funding needs. "They are learning to look at both sides of a question of what is prevention and what is care," Klocke says. "If we’re doing prevention services, counseling, and testing, we want to ensure that every new HIV-infected person has good resources as a step-up to care."
By combining prevention and care planning, the state is able to link those two areas more effectively. In fact in the state office, prevention and care staff work together, which makes communication between the two much easier, she explains. "So it’s yelling over the cubicle sometimes," Klocke adds. "We also have good service with data people about HIV trends and a good link with primary AIDS organizations and a good relationship with the University of Nebraska Medical Center in Omaha, which is our ADAP [AIDS Drug Assistance Program] partner."
At the front line of HIV care and prevention, providers and others working with the HIV population see better coordination of services. Everyone knows who to contact in care and prevention, and they respect each other, she says. "People understand that good care provides a direct avenue to some good prevention, as well," Klocke says. "If you have people in care who are taking medications, that’s a frontline prevention piece because their viral load is going to go down, and they will be living better lives."
Some of the efficiencies that have resulted from the collaboration include a shared staff person who is involved with both community planning and case management and care and Ryan White funding and prevention, Klocke says. "We share staff, broken up by payment source and the rest of the staff participates in activities as a team," she adds.
• Utah. An advisory council consisting of both prevention and care planners helped the state develop a plan that would combine certain meetings and put both planning processes on the same schedule, says Lynn M. Meinor, manager of HIV Prevention Program in Salt Lake City. "What we’ve done is combine orientation for all committee members and give them an overview of community planning and an overview of treatment and care," she says. Since recently beginning the collaboration process, there has been a noticeable effort toward partnership between service providers and prevention providers, Meinor says. "They now have more of an understanding from the orientation process and getting to know each member on that committee," she says.
"We’ve realized that we won’t be able to combine every meeting because our processes are so different, but there is more of a collaborative partnership that is strengthened." State HIV officials have discussed sharing staff between prevention and care, but that hasn’t been done yet, Meinor adds. "One other benefit is that we have committee members on treatment and care and also on community planning committee."
The state has formed a combined subcommittee about prevention for positives which includes members from both care and prevention groups, Meinor says. These members who serve on both committees are able to offer a different perspective about unmet treatment or prevention needs.
Theres a new trend in which state health departments are encouraging prevention and testing experts to collaborate with treatment and care experts. The goal is to increase efficiencies, save time, and improve communication between the two camps.
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