Is it time for the community to take a stronger role in HIV

testing?

How would that look?

James Tigchelaar

Research Question

What are the standards of practice and competencies necessary for people who were not legislated health professionals to competently conduct HIV testing.

Our Time Together

• Some Background• A bit of literature• Methods• Findings• Questions

Background: UCSF AIDS Health Project

UCSF AIDS Health Project

1986: HIV testing should be conducted:

• In an environment of support• With a health promotion and

prevention focus• With education – as knowledge

evolved

Literature

Not so great News:• Berman, P. A., Gwatkin, D. R., & Burger, S. E. (1987). Community-

based health workers: Head start or false start towards health for all? Social Science & Medicine (1982), 25(5), 443-459.

• Cherrington, A., Ayala, G. X., Amick, H., Scarinci, I., Allison, J., & Corbie-Smith, G. (2008). Applying the community health worker model to diabetes management: Using mixed methods to assess implementation and effectiveness. Journal of Health Care for the Poor and Underserved, 19(4), 1044-1059.

• Lewin, S. A., Dick, J., Pond, P., Zwarenstein, M., Aja, G., van Wyk, B., et al. (2005). Lay health workers in primary and community health care. Cochrane Database of Systematic Reviews (Online), (1), CD004015.

Kept Poor Records Criteria for Success

was Poorly Defined

Deficiencies inProgram Design

– Good news/Bad news

Literature – better news• Allan, B., & Leonard, W. (2005). Asserting a positive role: HIV-

positive people in prevention. New Directions for Adult and Continuing Education, (105), 55-64.

• Berman, P. A., Gwatkin, D. R., & Burger, S. E. (1987). Community-based health workers: Head start or false start towards health for all? Social Science & Medicine (1982), 25(5), 443-459.

• Hill-Briggs, F., Batts-Turner, M., Gary, T. L., Brancati, F. L., Hill, M., Levine, D. M., et al. (2007). Training community health workers as diabetes educators for urban african americans: Value added using participatory methods. Progress in Community Health Partnerships: Research, Education, and Action,

• Trussler, T., & Marchand, R. (2005). HIV/AIDS community-based research. New Directions for Adult and Continuing Education, (105), 43-54.

Strong understandin

g of population

health needs

Accessible

services

Well articulated staff

recruitment and eligibility criteria

Effective core training

Clearly defined

roles

Interplay of social, cultural

and health needs

Empower communities to

own control over their own services

Well trained

staff

Enhances policy and practice

Promotes health Builds

Community capacity

Methods

• Collaborated with AVI, HIM and ASK in designing and developing research

• Six focus groups in three areas of BC• Four focus groups with Community-

based workers (CBO, ASO), 2 with nurses

• Qualitative descriptive analysis of data

What is the best environment for HIV testing to be offered?

Regulatory Process

Standards and Scope of Practice

Employer Policies

Worker

Con

trols

on

Healt

h C

are

P

racti

ce

Competence

Themes and Categories

Responsibility to the

ClientResponsibili

ty for competent HIV testing

Responsibility for the

Environment

Client Centered

Care

Themes and Categories: Client-centered Care

“Our [CHW] success goes back to the strength of the relationship that we have with the individual, because [with HIV testing] if we know the person well, then some strain of pretest counseling would have to be released in there, right?”

“It’s one of the few strengths where the CHW has an advantage over the medical model because they’re able, and set up to, respect... differences in people. So there is a big benefit to the community health worker doing this work... chances are a lot better that [the client is] going to get culturally competent... or culturally sensitive care.”

Relational Practice:

A little less enthusiastic:

Themes and Categories

Responsibility to the

ClientResponsibili

ty for competent HIV testing

Responsibility for the

Environment

Client Centered

Care

HIV testing

Skills

Service design and

delivery

Themes and Categories: Skills re: HIV testing

“We get info-line calls that are pre and post-test counseling. People are constantly calling or dropping in because they don’t know what they want, and that’s a pretty good argument - we do pre and post test routinely, we just don’t offer the test.”

“We have to keep in mind that [positive] diagnosis creates trauma – this is an already traumatized population, and the CHW must be able to work with a re-traumatized person in the event of a positive result.”

We’re already doing it:

But be cautious – it’s not that simple:

Themes and Categories

Responsibility to the

ClientResponsibili

ty for competent HIV testing

Responsibility for the

Environment

Client Centered

Care

HIV testing

Skills

Service design and

delivery

The Communit

y

The Agency

(NGO,CBO)

Themes and Categories: Relationship to Service Design and

Delivery

Participant 7: “You have to educate yourselves about the cultures within your communities and stay culturally attuned. It may mean participating in cultural events in the community”

Participant 16: “I’d like to broaden that... what about the influences of 25 years of substance abuse, or if they’ve lived in 40 different foster homes, or spent 28 years in jail... there is a prison culture as well. We [have to] tailor our approach depending on what their culture is like.”

“I would argue that there’s a barrier to access within the current system design... maybe there are people who want to hook into the system in a lower barrier way, and the uniqueness of the CHW is that they can offer that. So why would we re-create mini versions of [the medical system] in the CHW, because that’s what not working....”

Don’t repeat mistakes:

Cultural Competence:

Themes and Categories

Responsibility to the

ClientResponsibili

ty for competent HIV testing

Responsibility for the

Environment

Client Centered

Care

HIV testing

Skills

Service design and

delivery

The Communit

y

Monitoring and

Regulation

The Agency

(NGO,CBO)

Conclusion

• The literature argues that community-based health services have to be done properly to succeed – focus group participants agree.

• Community-based focus group participants feel that they are ready to provide HIV testing – with some conditions

• They named six categories (or standards), with 66 associated competencies.

What do you think?

• How to proceed in the absence of a monitoring framework…

• Does this even matter?

Thank you

• Hans and Wayne from HIM• Andrea from AVI• Joanne from ASK• Meaghan, Daphne and Liz from

BCCDC• Focus group participants