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An Interview with the Prevention Pro
 Liisa
Randall has had her finger on the pulse of prevention for as long as anyone can
remember. She began in the former SOAP office way back in May of 1988. At the
time Randall was working towards her PhD in medical anthropology. Now Dr.
Randall, she has been the coordinator of the HAPIS - HIV Prevention Community
Partnerships Unit since it was created in 1999.
In January Michigan HIV News explored several issues with her, including:
Advancing HIV Prevention, the national Centers for Disease Control and
Prevention’s (CDC) controversial initiative announced last year.
Advancing HIV Prevention (AHP)
The CDC initiative has four specific strategies, but it “all falls under the
rubric ‘prevention for positives’” said Randall. And “it wasn’t new stuff.” The
initiative was “CDC’s attempt to put more emphasis on underutilized strategies.”
The nation as a whole and Michigan specifically, has reached a lot of plateaus -
in the epidemic, interventions and identifying new cases said Randall. “We’ve
been in cruise mode for a long time. The number of new cases of HIV/AIDS
diagnosed over the past five years has remained flat as has the volume of tests
that are conducted, both in Michigan and nationally.” So this CDC initiative,
“Advancing HIV Prevention was really an effort to refocus prevention efforts to
utilize underutilized strategies.”
“It shook a lot of people up (nationally)… It hasn’t had that big of an impact
in Michigan because that’s the direction we were going anyway…A lot of the
changes we have had to make are technical things – to meet the specific mandates
or the specific reporting requirements. The biggest changes for HAPIS and the
ones that affect community partners the most,” said Randall, “are in our
reporting of service statistics and evaluation.”
For more on the CDC initiative, “Advancing HIV Prevention see the website
(http://www.cdc.gov/hiv/partners/ahp.htm#announcement).
Prevention for Positives
A big emphasis of the CDC initiative is to find those who are HIV-positive with
expanded testing, get them into treatment and target prevention programs to them
rather than the greater circle of those at-risk. HAPIS was already on that road
of developing a prevention program tailored to persons living with HIV/AIDS.
HAPIS collaborated with the Midwest AIDS Prevention Project last year to do a
pilot project, POP - Prevention Options for Positives, a theoretically-based
intervention targeted to HIV-infected men who have sex with men. However, in the
last round of prevention funding (a three-year cycle which began in October,
2002) there was not a “large number” of agencies that applied for funding for
programs targeting HIV-positives. Four agencies statewide now have programs and
“there are an additional handful of agencies that have expressed interest in
ramping up for that in the next couple of years.” See the HAPIS - Prevention
Options for Positives Executive Summary and more on POP on our website. http://www.mihivnews.com/features/positively_prevention.htm
What about the new AHP emphasis on testing by medical providers?
There has been a lot of attention and concern with this aspect of AHP, both here
and nationally said Randall. “There are obvious issues about quality services,
about providing appropriate prevention messages, about preparing providers to
have the right skills to do risk assessment, risk reduction…all perfectly
appropriate things to be concerned with.”
And there is also the issue of linkages between public health and private
medical providers. Some states have well established and strong linkages between
public health and medical providers for prevention services, others do not. She
said working with these medical settings to provide testing is appropriate,
especially when you look at the “missed opportunities” that become obvious
reviewing the epi data.
MI surveillance data clearly demonstrates that a significant number of
HIV-infected individuals are identified, and therefore referred into treatment,
very late in the course of their infection. “So they don’t get the full benefit
of either therapeutic intervention or prevention intervention. We have seen that
all across the country,” said Randall.
“Because testing is underutilized, underemployed in medical settings which are
seeing individuals who are at high risk but may not know it, and because these
individuals are not accessing publicly supported services,” providing testing in
medical settings such as hospital emergency departments and community health
clinics “is an appropriate thing to do from a public health standpoint.”
Unlike many other states now grappling with the AHP, Michigan created a group of
communicable disease laws back in 1988 to deal with many issues around HIV.
These laws help to ensure quality prevention services in both private and public
sectors. Michigan law supports informed consent and the provision of counseling
with testing; and it specifically mandates the counseling and testing of
pregnant women unless they refuse the test.
“Our job under AHP is to help to ensure that physicians and other health care
workers understand their patients’ risk for HIV and have the knowledge and
skills to provide quality prevention services,” said Randall. The CDC is working
closely with national organizations, such as the American Medical Association
and “disseminating guidelines around counseling, testing, and referrals and to
provide appropriate training opportunities for physicians and health care
workers.”
HAPIS works toward the goal of educating physicians and other health care
workers within the constraints of limited funding. They work with the Ryan White
CARE Act funded Midwest AIDS Training and Education Center – Michigan at Wayne
State University, which does medical provider education. They are also building
bridges of collaboration. For example they are working with the Michigan Primary
Care Association to implement HIV testing at Federally Qualified Health Centers,
focusing on those with high-risk prevalence. FQHCs include community health
centers, tribal health clinics, migrant health services, and health centers for
the homeless. Anyone with Medicaid or Medicare may go to a FQHC for health care
services. They are usually in inner-city and rural areas.
“And we continue to work with hospitals where there have been missed
opportunities with perinatal transmission,” said Randall. “We are also working
with the emergency department at Detroit Receiving Hospital to implement routine
HIV testing.” “I want to be very clear that we are not saying ‘Test everyone.’
We are not saying to physicians do whatever you are going to do without
appropriate counseling or referrals. The idea is to help individuals learn their
HIV status and facilitate their entry into care and treatment services.”
Rapid Testing
Liisa Randall has been a proponent of rapid testing for years, waiting patiently
for the FDA to approve a test that was viable for use in counseling, testing and
referral sites in Michigan. So I was surprised when she seemed less than
enthusiastic when I asked her about CDC’s emphasis on rapid testing in the
context of AHP.
“Rapid testing is a tremendously valuable tool for prevention, just like OraSure
was eight years ago. It gives both providers and clients another option.
However, implementing rapid testing is highly complex with a lot of moving parts
and it continues to be challenging to attend to all of them…It’s exciting to
have it in place,” she said. But the requirements for those agencies who want to
do this test are “huge.”
The CDC initiative has placed a lot of emphasis on rapid testing “without a lot
of good strong explanation of where it’s appropriate to do, when it’s
appropriate to do, and the capacity that’s required to do it.” If you talk to
any of the agencies that we are supporting through our pilot project, they will
say ‘We didn’t have any idea what we were getting ourselves into.’”
“What people don’t realize is this is not OraSure. This is conducting a
laboratory test* (see below), not just collecting a sample. And it requires
attention to detail. It requires a whole different set of technical knowledge,
and it requires a whole different set of skills than most of our HIV test
counselors now have.
“And it isn’t just doing the test.” There are a laboratory quality assurance
requirements and regulations. “You have to get liability insurance, arrange for
medical waste disposal, purchase the right kind of lancets, monitor the
refrigerator temperature, conduct controls every day, record the room
temperature everyday, record the date that you opened a box of test devices, the
lot number for each test…And for CBOs that are struggling day to day to keep
their lights on, let alone trying to prepare and adhere to a complicated quality
assurance protocol ….There’s a lot of moving parts that make it terribly
complicated…The test is easy. It’s all of the things leading up to it and after
it.”
Even so, rapid testing is an important tool. It just needs to be used
properly...in a way that’s most efficient and effective. I’ve been pushing for
this for years, because I think… it’s a useful tool. But I also don’t think we
should all just jump into it.”
So it’s unlikely that you will see a lot of new venues providing rapid testing
for special events like National Test Day, or in some outreach venues such as
bathhouses, like the Seattle-King County is doing. Besides the technical issues
of administering the test, there are a whole host of counseling issues for
conducting a rapid test at special events and in specific public settings, like
“ensuring that clients are ready to receive results,” said Randall.
Rapid Testing Pilot Project
Six sites around the state were selected for the pilot project: the Kent County,
Oakland County and Detroit Health Departments, Community Health Awareness Group
in Detroit, Community Health Clinic in Traverse City and Visiting Nurses of
Southeast Michigan. The selection was made in part based on the communities that
these agencies served and by the capacity of the agencies and their staff to
quickly adopt this new technology.
Randall said the CDC was aware from the clinical research studies of the test
that “adoption of the technology by counselors and administrators was sometimes
difficult….because it was such a shift in the counseling messages and in the
informed consent, the decision making process around the test.” HAPIS wanted the
more experienced counselors who were most skilled and most competent be the
early adopters. In the first round of HAPIS training 18 counselors statewide
participated and there has been a subsequent training of 18 more.
Another criterion for choosing the pilot sites was low return rate of clients
who took the standard HIV antibody test. With the new rapid test, Randall said
of those who have tested reactive, “every single person (19 at last count in
January) got a confirmatory test and received their confirmatory test result.”
Those same sites have not seen an increased return rate for traditional testing.
So obviously, rapid testing is increasing the ability to inform more individuals
of their HIV status and get them into the system for prevention and care.
So, Randall is still backing the rapid test, just not without the caveats. And
she doesn’t see the process getting easier anytime soon. In fact it will only
get more complicated with the introduction of additional rapid tests that can be
used together with OraQuick to confirm results. Now the initial rapid test must
be followed up by a traditional Western Blot confirmatory test. Rapid
confirmatory testing in the field will double the complexity of the testing
process, “you’ll have two different sets of quality assurance to attend
to…different timing, different temperature controls.”
And it’s very important that individuals do the follow-up confirmatory testing.
Rapid test counselors can not make some necessary referrals for HIV-positive
testers on the basis of the screening test. “It is not a confirmed diagnostic
result,” said Randall. “We can’t make referrals for PCRS (or) medical care. But
certainly referrals for psycho-social support or crisis management or other
prevention services are made as appropriate.”
In Conclusion
The reality is funding for HIV prevention at flat or reduced levels and the
federal government (at least through the end of this year) will continue to act
conservatively when it comes to supporting prevention programs.
“We can expect that the bar of accountability will continue to be raised,” said
Randall. “To ensure that we continue to be accountable to our communities as
well as our funders we will continue to emphasize highly targeted and
evidence-based programming. We’ll also continue to innovate – look for and adopt
new strategies that will help us provide high quality services responsive to
community needs and priorities.”
Michigan, for all of the casualties in the process of reform, is still ahead of
the game. Randall and her team will continue to keep their eye on the ball, to
work with other DHAS-HAPIS units and MDCH departments, the Michigan HIV/AIDS
Council, contracted agencies and collaborating entities to keep prevention
activities in the real world and make prevention dollars accountable at the same
time.
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