The Solution Part One: Testing
In attempting to create a focused, working HIV prevention model, it is important to take into account two separate groups and strategies. Two groups to target are those who know their HIV serostatus and those who don’t, and strategies for targeting those groups are prevention and testing. For Santa Clara County in particular, these strategies focus mainly on MSM. In 2003, the CDC estimated that up to 25% of the nations HIV+ are unaware of their serostatus (Glynn, et al.). To truly combat HIV/AIDS from the ground up, the entire community must be involved in the effort, from hospitals and clinics, to community groups, to drug stores selling needles. If just one group makes a significant effort without input from all other groups, any prevention effort will fall apart.
In this day and age, many people have moved past the AIDS hysteria of the 1980s and 1990s, perhaps simply because treatment has improved, and HIV/AIDS is seen of as a manageable chronic condition, rather than certain death. Thus, motivation to get tested is low (Beall, Jr., et al.). Any successful testing campaign needs to offer HIV testing as a routine and normal part of health-care to attempt to reduce stigma. In one study, doctors’ and nurses’ attitudes and actions toward routine HIV testing in emergency-care centers were surveyed (Fincher-Mergi, et al.). A huge problem with doctors recommending testing in all cases in which HIV testing should be recommended is the burden placed on doctors and health care providers when it comes to required pre- and post-test counseling. Currently in California, there is a bill being drafted that would lessen the burdensome requirements for pre-test counseling, thereby increasing the blanket number of people who are being tested (Mulhern-Pearson, et al.). This strategy is being advocated by the CDC (CDC HIV/AIDS). Also, a problem in general with testing in Santa Clara County is the lack of many small, convenient rapid-test centers. Currently, there is only one anonymous-testing center in Santa Clara County, the Crane Center (The Crane Center), with confidential testing also being offered in various other sites throughout the county (STD Testing Sites). Even if this bill does not pass into law in California, it is important that hospitals begin to offer HIV testing routinely for anyone with risk factors, instead of just in extreme circumstances. This could be done more easily with routine hospital check-ups and visits, rather than just in hospital emergency rooms.
In creating an effective solution for the HIV problem in Santa Clara County, it is clear that multiple smaller quick-testing centers need be open at convenient times for a working population and in convenient areas. Currently, the one testing center open is located in downtown San Jose and is open on Monday, Tuesday, Wednesday, and Friday from 8:15 a.m. until 4:15 p.m., and on Thursday from 11:15 a.m. until 8:15 p.m. It is closed during the lunch hour. This is an issue, because people who might want to use this center may not be able to miss work in order to come to the testing center, and it is closed during more convenient times of the week for those people. To be more effective, it should be open during non-work hours in the day and run by volunteers, who may be more willing to work those odd hours. Alternatively, with many other smaller HIV testing sites, the Crane Center could operate as the main administrative center, and be open during normal office hours, and liaise among other testing centers in the county that are open at more convenient times for the target population.
Another issue with this center is its location. Although the highest population density is in San Jose where the Crane Center is located, San Jose does not have the highest AIDS rate in the County. The highest AIDS rates are in Campbell, Mountain View, Santa Clara, and Los Gatos. In this plan, the Crane Center in San Jose will be open as a main testing site. It will offer STD and HIV testing, and it will offer both the twenty minutes OraQuick test, as well as the two longer tests – EIA and Western Blot. Satellite sites would be located in the three other areas with the highest rates, Campbell, Mountain View, and Santa Clara, and they would offer just the quick test. These sites would be open, in general, from around 4 p.m. to around 11 p.m. on weekdays, and on select weekends, enabling the working population to receive testing without jeopardizing jobs and relationships. After 11 p.m., there would be a “late-night breakfast buffet”-type van that can operate throughout the county and target high-risk areas. The late-night breakfast buffet was a van that operated a needle exchange, and STD and HIV testing and counseling for six months in San Francisco (Rose, et al.). A model like that would be useful in Santa Clara County as well. The van would go to four set locations in Santa Clara County – Campbell, South San Jose, Mountain View and Santa Clara – each for 45 minutes and 15 minutes travel time. With a regular schedule, this van would establish a rapport, and people would start to get to know about it through word-of-mouth, cutting down on the need for advertising expenses, except for within the Crane Center and the satellite centers themselves. The three satellite centers and the traveling van would obtain their main inventory of OraQuick tests from the Crane Center.
Even with all these extra testing centers, persuading MSM to get tested will not be easy, because of the issues mentioned previously, such as condom-fatigue and the “down-low” issue. One method that has proven effective in identifying new cases of HIV has been a peer-referral program. In one study, 5% of recruited “peers” who had not previously been tested and were unaware of their serostatus were HIV+ (Golden, et al.). Recruited men also tended to have similar high risk behaviors as those who recruited them, indicating that this could be an effective means of targeting high-risk, but reluctant, populations, if even a few members of those populations consent to be tested. In this program in Santa Clara County, everyone who gets tested should be encouraged to notify not only their partners, but anyone with whom they might engage in high-risk behaviors (such as intra-venous drug use), or any friends they have whom they know engage in high-risk behaviors. In this way, testing can get to hard-to-reach populations.