Taking HIV prevention to the streets
By Jessica Ullian
Since its creation three years ago, the Center for HIV/AIDS Care and Research at Boston Medical Center has provided testing and counseling services for the hospital’s at-risk patients — including those without jobs, homes, and health insurance. Now, in an effort to make testing even more accessible, the HIV and AIDS counselors will take their practices out of the hospital and into the neighborhoods of Dorchester, East Boston, and Mattapan.
The Centers for Disease Control and Prevention awarded a five-year, $2.25 million grant to the Center for HIV/AIDS Care and Research in July, to expand counseling and treatment options in 5 of the hospital’s 15 community health centers. Boston Medical Center currently reports more HIV cases each year than any other hospital in the state, according to Paul Skolnik, the center’s director and a MED professor; the grant, part of a nationwide effort to advance HIV-prevention initiatives, will help the health centers reach even more underserved populations.
“The goal of all this is to test as many people as you can, and identify as many positive people as you can,” Skolnik says. “We think this is going to be a great advantage to making sure that the counseling and testing program works well.”
The funds will be used to place a full-time HIV counselor at BMC and five affiliates: Boston Health Care for the Homeless at the medical center, Mattapan Community Health Center, East Boston Neighborhood Health Center, and Dorchester’s Upham’s Corner Health Center and Harvard Street Neighborhood Health Center. By targeting different neighborhoods, the Center for HIV/AIDS Care and Research hopes to reach the statistically at-risk populations, such as intravenous drug users and the homeless, that might not take the initiative to get tested.
“Right now, people come here for all their testing,” says Jon Hall, the manager of HIV/AIDS clinical affairs at BMC. “This way, we can sort of go to them.”
The CDC estimates that up to one-fourth of the HIV-positive people in the United States do not know they have the virus, and that 31 percent of those who test positive at public testing sites never return to get their results.
That data, plus an apparent increase in national infection rates for the first time in 10 years, illustrate the need for community-based programs such as BMC’s, Hall and Skolnik say. New rapid HIV testing can determine results in about 20 minutes, enabling health-care providers to start treatment and counseling in the course of one visit; as a result, counselors are asking patients about HIV when they come in for any kind of medical procedure, hoping to make testing and counseling an ordinary part of the health-care experience. “That’s what we do here at Boston Medical Center most of the time,” Hall says, “and that’s what works best.”
However, the counselors at the community health centers face some unusual challenges in serving Boston’s diverse communities. Recent immigrants can be difficult to reach, Hall says, because many people without legal resident status are reluctant to seek out health care. The homeless are often hard to locate for counseling or follow-up care. Prostitutes and intravenous drug users present yet another set of challenges.
In addition, the health centers are also dealing with a high proportion of low-income clientele who need to make day-to-day survival a priority over health care.
“Because Boston City Hospital and Boston Medical Center have always historically cared for indigent populations, we do have problems that others don’t face,” Skolnik says. “Many of these patients don’t have health insurance, but they also have a lot of those other problems. They may not have a roof over their head or food to eat.”
To deal with all these issues, the center’s HIV/AIDS counselors will test out different outreach activities during the first year of the program and then assess the needs of each neighborhood.
“I think we can all presume, going in, that if they’re Haitians, we should have a Haitian counselor,” Hall says, referring to the Mattapan center, which is expected to serve a large Haitian population. “But that’s not 100 percent true. Sometimes people don’t want to go to a counselor of their own ethnic group.”
Counselors also have site-specific plans for other neighborhood health centers: in East Boston, they plan to work with the courts, in order to reach people who have been arrested for drug use or prostitution; in immigrant communities, they will ask employers to refer their workers to the health centers.
The expansion of BMC’s testing and counseling programs has already begun. Vanessa Sasso, previously the program coordinator of HIV services at the Upham’s Corner Health Center, has been hired as program coordinator, and Skolnik expects to soon hire a quality improvement coordinator to handle data management. A search for counselors will begin in the near future, with the goal of placing counselors and testers at each site by January 2005.
“We’re pretty happy,” Skolnik says of the grant. “And we’re confident that we’ll be able to help the health centers do this in a very efficient and a very good way.”