An Interview with the Director of HIV/AIDS and STD

Michigan HIV News, Winter 2000 Issue

Loretta Davis-Satterla took on the job of the first director of the Division of HIV/AIDS and STD for the Michigan Department of Community Health in July, 1999. For background on this new position and the new responsibilities, see People on the Move. The following is from an interview with Michigan HIV News on January 10, 2000.

At the Care conference last summer you said there would be "changes to the way business is done." What is your perspective on that now?

Davis-Satterla said she had found this to be a positive thing, that there is already a lot of collaboration and overlap between prevention and care at HAPIS and in the STD section. "So the changes will be much more subtle than overt." There are already a lot of changes going on, said Davis-Satterla, for example the STD staff was in need of training and updating and rather than creating a training unit for the STD section, the HAPIS Training Unit, under the direction of Ellen Ives, is doing the training for the STD staff. "And that is working our really well."

Another area of merger is in the quality assurance that the state provides to local health departments. Where before both HAPIS and STD staff would do their own, there will now be a coordinated effort with cross training of staff so they will be able to review either section.

As Davis-Satterla mentioned this summer at the Care..Prevention..Care conference, "There will be a functional blending more than anything else....if there is a function that will be better facilitated through one person at HAPIS."

For example, contracting and contract monitoring will become a collaborative effort between the prevention and care units of HAPIS. "This year the state went to what is called a 'master agreement' relationship with agencies and one person from HAPIS will now be responsible for this."

Staff meetings are now held divisionally. These are held quarterly and give the opportunity for everyone to have a better understanding of the programs and what people do. "And with a better understanding, many times comes a better appreciation for what the rest of the staff is doing." The more that staff understanding and appreciation for one another happens, Davis-Satterla thinks "staff will then be better able to come up with various different areas where collaboration and blending can occur."

The first staff meeting discussed the new challenge of hepatitis C and how that may need to be woven into what they do. "We are talking about a similar population as it relates to ID use, though not so much with sexual transmission (See the last issue of Michigan HIV News, feature article on hepatitis C.)

The hepatitis C issue was a topic of discussion at a meeting of the National Alliance of State and Territorial AIDS Directors (NASTAD) that Davis-Satterla had attended. Most of the state directors feel there is already too much on their plates for HIV prevention, she said, especially with the new initiative for secondary prevention activities to take on another unfunded activity. "It would be short sighted to say that while we have already got them there to talk about HIV prevention, we can just tag on a hep C message as well....that just doesn't work." The CDC indicated at the NASTAD meeting, however, that there may be in the future a CDC hep C coordinator at the state level as there is now with hep B.

(Since this interview the State has allocated funds to initiate hepatitis C prevention in Michigan, specifically to train counselors and to cover hepatitis C counseling and testing for about 6,000 individuals. Six counties in the state were selected by risk factors for this pilot project. This is expected to begin October 1, 2000)

Acknowledging that you come to the state to serve all of the people, you come to the position with the unique perspective of an African American woman. How does this affect the way you do your job?

"I think it influences it in a very positive way. Because not only being an African American woman but also having worked so closely with southeastern Michigan, it is clear to me what is happening within the African American community. I feel that I am in a good position to address that, to speak on that and kind of move that to a high priority -- as I think the entire state would agree it has to be -- and I think the nation would agree it has to be. It's a conversation that is going on all around the country because the same is being seen, in many pockets - particularly cities - all around the country. Having worked with the Michigan Women and AIDS Committee for many years and seeing the faces change and the numbers of women grow and those faces become younger, it makes me keenly aware that we have a lot of work to do.

"Also, being an African American woman, I do understand how difficult it can be for women in our culture to be able to say, 'I am an IV drug user,' or to have power in relationships to be able to do some of the things that it's going to take to remain safe. And so that's always ever-present in my mind. How do we do this in such a way that women are really able to incorporate these messages into their lives and not base it on someone else's life who may have a lot of power, including income and credit cards and a place to go, and a support system that may not be there for African American women that are most at risk. Those are the perspectives I think that I bring to it. Also, I think that I have had inroads into that community and with professionals who work with African Americans at risk and I intend to work with and use those and we move along and look at what we really need to do in terms of targeted prevention."

Another perspective that you bring is your history with Planned Parenthood, where there was more of an emphasis on STD prevention. Now that we know HIV and STDs are clearly linked and they need to be connected, I would imagine that helps a lot in guiding this program.

"It does. Having working in both arenas (HIV & STD) it seems to be clear to me how to take the positives from both sides and incorporate those. Certainly there is a lot to learn from the STD experience because we have had a longer track record and there is a lot to learn from HIV in some of the ways we have been able to incorporate the voice of the community. And I think we are going to really see this with the syphilis elimination project, because it has a big community piece and that's a big departure from the way people think about traditional STD approaches, which is to go in, find partners -- to do it more from the professionals looking for the contact and those who may be infected. (The syphilis elimination project) really incorporates the community's voice and strategizes with the community. That's something that STD can learn from HIV. And visa versa, there is a lot of learning that can occur from both.

"My experience with Planned Parenthood has been helpful from the very beginning, working with HIV. That experience taught me to sit down and communicate with the client. And they will tell you how they can work certain things into their life -- if you just lay out the facts and then listen to them while they show you how they can or can not incorporate that into their lives.

"The other big piece is that HIV, like the other STDs, really is about sex. It's about sex and drugs. But it's about sex. Being able to be comfortable with that and also helping those who are in traditional family planning settings, to really work with the special issues around HIV, I think has been a benefit."

How would you qualify the situation currently for African American women, in terms of both prevention and care, here in Michigan compared to other states?

"In terms of care, I would say that we are excellent. When we look at the URS data* and compare that with the HERS data we see that the numbers of African Americans in general and African American women as well who are being seen -- at least through Ryan White services -- either match or exceed the numbers that we know to be living with HIV. That really speaks to the fact that we are reaching the population that has been identified as living with HIV and AIDS. So that's a positive.

"Looking at numbers of deaths that have declined for the past two years, in Michigan, we have seen this in the African American populations as well as for whites. And that was not seen in some other cities and states. So that's a real positive for Michigan and for the leadership we have always had in Michigan. And it speaks a lot to access, of course. You know the drugs can be there and the physicians can be there, but if people don't want to come, they will still get sick quicker and die. But we have seen the access has been very good for even our hardest to reach populations, so I'd give us an 'A.' Yes, I'd give us very high marks.

"In terms of prevention, it seems like we are pretty much matching or paralleling what we are seeing around the nation and that is a kind of flatlining. Where at first the infections rates were very high, now we've reached a point where they are not going down. They are just staying level. Some would say that's good because they are not going up, but then others of us would say 'ok we've had this flatline for a while, now it's time to start making a dip.' You have to because, as people live longer, and they are healthier, we have more people living with HIV in our population. And that's good because they are living longer and healthier. But if you have a flatlining of new infections while the number of people living with HIV continues to grow, it does put an increased stressor or burden on the systems that we need to put in place. And of course prevention is what we are really seeking. So we need to start seeing a dip.

In order to do that, I think most would agree, we have to really look at targeted approaches, finding those who are most at risk, getting interventions to them that they are most likely be able to incorporate into their lives and reduce their risk for HIV. Now it may mean that they are still not living in situations that some may feel are the most positive and healthy situations for a person to be living in. But we are talking about decreasing the risk of HIV. And that is the focus that we need to take. So we need to look at targeting populations - racial and ethnic populations - but never forgetting the behavioral link to the disease so it's those who are practicing high risk behaviors. I think that we are getting there. We are at least starting to talk about it around the nation and in Michigan. So we'll get there."

There is a certain limit to what you can do top down in state government because of the community planning process. Do you see a future merger between STD and HIV at the community planning process level?

"We have not talked about that. We've not really looked at that right now, because of the merger between prevention planning and the care council. It feels like that's probably enough on their plate right now. There's going to be a need to figure out how all of that works without adding an extra element which is STD. Certainly STD is going to move into more of a community voice, particularly driven -- again by the syphilis elimination plan. But at this point there has been no discussion about trying to incorporate, fully, STD into the community planning process."

You already touched a lot on the underlying issues for women. Do you see the prevention contracts from the state moving more into addressing these underlying issues?

"So far the community planning process has been really good in identifying the local needs. And probably what we will see is that the community planning process continues to work and they continue to tease out and work through all of these issues. I think at the community level we are going to see that more and more being prioritized. And then, of course our fees and our dollars will follow those issues that the community has identified as being very important -- certainly for those communities that have a large population of African American MSMs and African American women. Certainly the expectation would be that they would prioritize those populations highly, because clearly the (epidemiology data profiles) show that this is a population that is ever growing in their risk of HIV."

On the Syphilis Elimination Plan

"It's a five year plan, hoping to have transmission down to just a few cases annually. ... of course the resources have to follow the (Centers for Disease Control) verbal commitment. CDC has been putting some resources into that and given guidance that 25% of these resources given to a state have to be given to a (CBO). And I see that as very positive. If it is going to be community driven, then the community will need some resources to be able to incorporate that into what they are already doing. What we are talking about is agencies that are already busy, probably their funds are already pushed to the limit (providing) other services. This is why we would be looking to them for assistance in the syphilis elimination campaign, because they are already seeing the population. And we would not want to give an unfunded initiative to them. It just doesn't work.

The dollars seem to be following and the time frame seems to be fair. If they wanted us to eliminate syphilis in the next 9 - 12 months that would be impossible. But over the next five years is very doable. Nationally we are at some of our lowest rates...so the time is now. But again, if we let this opportunity slip away, then it's gone and we have to wait again until the time is right..and the time is right now, and we continue to move towards it..

The target, because of statistics, is the City of Detroit. So our efforts will be centered in the city of Detroit and the community-based agency or agencies that we partner with. Because that is where the morbidity takes us."

On the Anonymous testing vs. Names-reporting issue -- the CDC has recently come out with a new policy statement that was "lukewarm" in support of the anonymous testing option. In Michigan, we had addressed this issue back in 1988, with Act 49 which addressed HIV reporting. There is now rumor that the state law is being reviewed.

"What has happened is that there has been an opportunity for....different government bureaus, divisions and offices to review the various parts of the public health code that affect or guide the way they do business. The approach has been to bring the public health code more in line with what is already happening day to day. Things have changed since the public health code was written, especially in those areas of public health where there has not been a lot of new legislation around it. For HIV, the legislation has been fairly active over the years, and has pretty much kept up-to-speed with practice.

So, the public health code pretty much reads the way things are actually done in HIV. I think that people got a little bit nervous when they heard that the public health code was being reviewed and what that might mean. But it's not just focusing on the communicable disease section, which would cover HIV and STD and other serious communicable disease. It's looking at the whole thing and making sure it wasn't archaic and then bringing it up today's practices. I see it as a real potential positive.

And as you say, Michigan has long ago figured out the names-based reporting and the anonymous option, and that has gone very well. As I looked at CDC's guidance and Dr. Johnson (title here) looked at it, we saw nothing Michigan would need to do different in order to be in-line with those recommendations."

So you don't see this as an opportunity for the legislators to remove the anonymous testing option?

"No, there has been no discussion at the state level that I have been privy to. And, even though the CDC statement may not have been the strongest around that issue, it was still clear that CDC was in support of anonymous testing. And Michigan has always been in support of that; I don't see that changing."

How do we balance that need for surveillance information with the need to protect people from discrimination and possible recrimination, especially when we are talking about women?

"It's a very careful balance. And I just have to say it again, because Michigan has been doing names-based reporting for so long and it's been uneventful in terms of any breach of confidentiality or it being used in ways that harm people. I think we have a really good track record on that. The key is, I think, that we still have an anonymous option for those who really want to not have their names connected with their results. The fact that there is the anonymous option has been very positive. The other thing is, Michigan laws are really clear about protecting the confidentiality and also attaching penalties to that, because people still do respond to penalties. Michigan has been very serious about the need for confidentiality around this whole issue and has a really good track record with it.

The names need to be used in very specific ways, because there is a need to be able to really define the epidemic as it now and where it's going. And that's really the key. You have to be able to look at where the disease is going. That's where surveillance and the epi really helps us. Without that, it becomes like swimming with your eyes closed groping for the answers, or the shore, if you will. So, in that sense it can be very positive, but you just have to be mindful of how the information is being used. And limited access and never becoming lax because we have been dealing with this disease oh so many years..not ever forgetting that this disease does have some special qualities that can lead to some very real discrimination in both a professional and a personal way.

Even though I am a real supporter of being able to blend in some HIV activities with STD activities and visa versa and learning from each other, that does not mean that we should forget the very special qualities around HIV....again that could lead to discrimination on various different levels. And we have to remain mindful of that, both from the programmatic standpoint as well as from the epi and surveillance standpoint, and work very closely together to be able to answer the questions to design programs and to set out initiatives. But also being always mindful that it can't go so far that people's confidentiality is compromised. So, it's a balancing act but, again, one that we have a good track record with. So, that's a real positive. I can't say that enough.

I know I feel good from the position that I'm in not to be starting from ground zero as some other states are, wrestling with this issue of names-based reporting or unique identifiers and where that might go. Because we have been doing it so successfully. Again, the CDC's recommendation does not change the way we do business, but actually may put us even more in a position to give other states guidance on how it might be done and done appropriately."

What do you see as the biggest challenge DHAS faces this year?

"The biggest challenge is to make sure that each section maintains its own identity while working together in terms of a divisional approach particularly on certain issues. There is a positive effect when you get synergy working. Both sections have done incredible work on their own. We think this will make a very positive impact on the state. Another challenge day to day is the question of how to define our role and who does what with the addition of a divisional director while making sure that neither section is watered down in what (each manager) and staff are able to do. So far in the past six months, I think we have been able to do that quite effectively."

On the Michigan Women and AIDS Committee

The role of chair has usually fallen on the responsibility of the HIV/AIDS Program Coordinator at the Detroit Health Department, the position Davis-Satterla held prior to becoming the DHAS director in July, 1999. She was the chair of this committee for five years.

"In the early days of Linda Campbell and Joan Fields it was a lot about being a voice for women who had no voice. The times were very different -- there is still a lot that needs to be done -- there was not a female face being put to HIV. So we worked a lot around that. We moved into doing a lot of direct work with women who were most at risk or with entities that reached out to women. We were one of the first to bring (prevention) initiatives into beauty and nail salons. When women go into salons we share stories, we share facts we share myths. The Michigan Women and AIDS Committee was very active in doing activities directly into the community. As we went on our major focus became the conference, but we wanted to make sure that the conference (addressed) not only professionals working, but also had tracks directly for consumers. It was an opportunity for us to get a message directly to the consumers - to have an opportunity to see how that might fit into their lives."

At first the conferences were held once a year but that took all of the energy of the committee so they decided to go to every other year to be able to do other things as well, "very important but smaller projects throughout the year." One year this was a mentor-mentee project which paired professional women with consumers. "Those who stuck with it really found it beneficial."

"We would listen to what the women said they needed. When they said they were feeling better (due to medications) and were ready to start looking for a job, they needed the right clothes." So that year the Michigan Women and AIDS Committee sponsored a holiday party with a fashion show and 'shopping spree' of donated clothing.

This initial effort, which "was an incredible success" has perpetuated as a clothes resource center at H.E.L.P., where professional women continue to donate clothing. "This project was a good example of how the Michigan Women and AIDS committee has brought in partners from business outside of the AIDS community to help and get them involved.

."There have been many things that I have enjoyed (in HIV/AIDS work), but this is one of the things that I have truly, truly enjoyed, because the women, and sometime men, who come to that table come with a real desire to make a difference in the lives of women, either from a prevention or a care standpoint or both. We have to always stay sharp and on top of things because when the women say this is something that we need or want, we have to go out and find someone to make that happen."

The Michigan Women and AIDS committee has always worked with limited resources and an all volunteer group. Davis-Satterela said that the success of the 1999 AIDS Walk in Detroit has probably helped out with the resources, but in the past efforts of the committee included finding partners in the community to help fund their initiatives. For the conferences, that had 350 attendees many of whom were consumers on scholarship, this took a lot of effort on the part of committee members.

"I think the Michigan Women and AIDS Committee has been a leader with the issues. The Michigan Women and AIDS Committee has a very proud history."