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Adolescent HIV Prevention Project 2004-2005:<br/>HIV Prevention in the Schools Demonstration Sites



“I cannot imagine that a LHD would not be delighted to collaborate on an initiative with a school. Our missions are both the same—to educate, to prevent problems, and to strengthen community residents.” Debra Katz, City of Stamford


NACCHO’s Adolescent HIV Prevention Project aims to enhance school and community HIV prevention programs through financial and technical support of innovative local health department (LHD) programs. The collaboration between public health and local school systems provides an opportunity to form comprehensive community and educational programs that can capitalize on each other’s resources. In 2004-2005, with funding from the Division of Adolescent and School Health at the Centers for Disease Control and Prevention, NACCHO provided $20,000 each to the City of Stamford, Department of Health and Human Services in Connecticut and the City of Portland, Public Health Division in Maine to expand their HIV prevention efforts in schools, focusing on high-risk youth in grades 7-12. 

In 2005-2006, NACCHO is providing $12,000 each to Collier County Health Department in Florida, and Washoe County District Health Department in Nevada. The demonstrations sites will plan and implement an innovative means by which to reach adolescents at highest risk of STIs and HIV and collect preliminary performance and evaluation data on the intervention.

Demonstration Site Activities

Because the project period for the 2004-2005 demonstration sites was only one year, LHDs with strong, existing relationships with schools, were selected through a competitive request-for-proposals process and challenged to take their programs a step further. Both of the selected sites took advantage of their access to youth through school-based health clinics. In addition, their efforts included working with youth in the classroom, in other schools settings (e.g. mental health counseling), and in community settings. Both demonstration sites addressed the broad spectrum of factors that affect sexual risk behavior, including mental health and substance abuse.

The City of Stamford, Department of Health and Human Services is located 45 minutes from New York City and includes a large number of recent immigrants and a relatively large uninsured population. The LHD has strong community ties that have been nurtured over a number of years, with school-based HIV prevention activities taking place for the past several years. Their “Frisky Business” program activities that took place in high schools included:

  • Sexuality counseling and age-appropriate educational materials for all students who present at school-based clinics for physicals, STI visits, and/or pregnancy tests.
  • Risk-reduction sessions for students referred for high-risk sexual behavior.
  • Classroom lessons in prevention strategies for high-risk sexual behavior.
  • On-site confidential HIV testing with a minimum of two counseling sessions in high school clinics.
  • 8-week risk reduction group sessions addressing substance abuse, HIV, and/or other STIs.

In addition, the City of Stamford added a program in one middle school, which included screening students for high-risk behavior and referring students as appropriate for modified 8-week risk-reduction sessions.

The City of Portland, Health and Human Services Department has the highest HIV infection rate in the state of Maine. Portland is a community that is gay, lesbian, bisexual, and transgender-friendly and is very diverse relative to the rest of the state, with over 40 different languages and dialects spoken in the schools. Portland emphasized a mission-driven rather than a budget-driven approach and used a complementary grant from the National Assembly on School-Based Health Care (NASBHC) that provided training and technical assistance to enhance their activities; the NASBHC grant assisted with the “how” and NACCHO’s grant assisted with the “what.” Their “HIV Prevention in Schools” program activities included:

  • HIV/STI prevention needs assessment of the school and community in collaboration with related coalitions.
  • Screening for high risk behaviors and one-on-one follow-up for high-risk students.
  • HIV testing offered at 4 targeted schools.
  • HIV testing offered by health department HIV/STI prevention staff at 3 community partner sites.
  • Prevention materials, including condoms, available to all students in the student health centers.
  • Presentation of CDC approved curricula in each of four targeted schools by health department HIV/STI prevention staff, including one middle school.
  • Dissemination of prevention materials from the health department through their community partners.
  • Printing and distributing 150 posters and 2500 flyers for schools and community sites, with written translations in the 8 major languages spoken in the community.
  • Holding World AIDS Day and HIV Testing Day events in collaboration with community partners.
  • Primary sponsoring agency for the Teen Convention, a community-wide youth health fair.
  • Participation in the Northeast Regional Minority Health Conference.

Lessons Learned

Establishing trust and productive working relationships with school and community partners is essential. Both demonstration sites started with strong community and school relationships and a history of having successfully implemented potentially controversial activities with minimal public objection. However, new relationships needed to be established to allow for the enhancement of activities and growth into additional schools. Sensitivity to the realities of competing demands on the school personnel making the decisions around HIV prevention and testing activities in their schools and the communities they serve was paramount to their success. One way this was partially addressed was through collaboration—running the programs, including the risk reduction sessions—with a combi-nation of school and LHD personnel.

"Don’t be afraid to go outside the walls of the fiefdoms to find solutions to your problems or to address the needs of your students.  Sometimes disciplines become entrenched in their own ideologies.  Educators speak in the language of Education and public health officials speak in the language of Health.  Both are important.  Both are compatible disciplines.  Putting the needs of students before the needs of the disciplines and their respective turfs usually results in mutual satisfaction and success. "

Lisa Belanger, City of Portland

Compromise was another part of developing successful working relationships. For  Stamford, this meant  no condom  distribution in the schools, despite being able to test for HIV and talk to students in detail about risk reduction. For Portland, this meant a more abstinence-based focus in a middle school site in which the students’ cultural backgrounds and religious beliefs often strictly forbade sexual activity prior to marriage.

In all cases, involving all the key stakeholders—school personnel, parents, students, primary care providers and related community agencies—in the planning process was essential to building support for the development or expansion of a project. The demonstration sites took steps to make certain that the principals and staff of each school were receptive to the programs proposed. The sites took small steps in implementing their programs and tried to address all concerns in an unbiased manner. They took time in working with non-supporters and also were prepared with the data to answer questions about and provide support for their programs. 

In building a relationship with the school system and acquiring a positive reputation, LHDs face many issues related to confidentiality, fear, lack of awareness, and sensitivity about HIV risk behaviors in adolescents. This required repeated school faculty trainings and discussions with both groups and individuals.  Patience and trust were critical to the integration of HIV education, counseling, and testing into the school. Both LHDs provided services on school grounds and therefore had to make accommodations accordingly. Although it took time to develop these relationships, the lasting partnerships benefited the students, the LHDs, the schools, and the community. For the LHDs, having more of a presence in classroom settings allowed them to increase their visibility and to become more integrated with the school setting. Successful programs also improved stakeholder support.  Community partners that collaborated on Portland’s Teen Convention were enthusiastic about the results and there was overwhelming support for the idea of doing the event again given the positive community response. 

School-based health centers were an important part of the partnership. Having school-based health centers on site at the schools was a key component to the success of the programs. Their presence made access easier for students, and the LHD had established connections with the school that made it easier to access students within a classroom setting and/or to identify students within the broader school population for health education and risk reduction activities. If HIV counseling and testing is offered by a public health department on site at a school but not in partnership with an existing school-based health center, the system for referrals, appointments, and assuring confidentiality becomes more difficult. 

Careful and thorough planning is a vital part of the process.  Logistical issues around where a risk-reduction group would physically meet, how students would be referred and attend without compromising confidentiality, and considerations regarding the practical implications of rapid vs. traditional HIV testing were all issues that had to be carefully considered. For one site, an unanticipated issue arose: high student demand for meeting with a newly placed HIV testing counselor led to the need for problem-solving with school personnel on how to manage the volume of students requesting to see the counselor and how to avoid having groups of students waiting in the hall outside the counselor’s office.

Because this was short-term funding, it was important that the goals of the programs were based on the resources and time available. Ordering and receiving necessary educational materials, attending state certification trainings, and pre-planning requires significant lead time. Connecting with key stakeholders and coordinating schedules can also be time consuming. In addition, school breaks, summer vacations, and start-up time limit the amount of time the programs can be implemented. With only one year of funding, it was difficult to assess program outcomes. The demonstration sites plan to leverage funding from other areas of their program in the next project year to continue their efforts and more comprehensively evaluate their outcomes.

"Schools are complicated places and the entire hierarchy—principal to guidance to faculty to nurse to educational assistants and students must have a commitment to making the program work. In addition, many people have issues and feelings related to HIV, condoms, homosexuality, sex and substance use and therefore, make sure to take small steps in implementing an HIV prevention program and address all concerns in an unbiased manner."

 

Debra Katz, City of Stamford

Another planning issue was regarding which HIV testing technology to use. At both sites, adolescents are free to be tested without parental consent. However, both had extensive discussions with the various parties involved around many issues, such as: balancing the practicalities of HIV testing; the relatively low likelihood of positive results; newer rapid-test technologies; the desire of youth for non-invasive testing methods; and the unique advantage of the low risk of non-follow-up that a school-based testing site provides. In Stamford, they decided not to use rapid testing with school-based youth, primarily because from their previous experiences, the waiting period was determined to be a useful tool in motivating students to reflect on their risk behavior and their potential risk for infection. In Portland, initial plans were to use rapid testing, however, several factors—including cost of low volumes of testing and the need to run parallel controls and concerns around giving a positive test result to a minor when built-in supports may not be as readily available as with a traditional waiting period—led to the decision to only use oral and blood tests. The oral test kits arrived later than the blood tests, and as many students preferred the oral test kits to blood tests, they chose to wait until the oral tests arrived.

Ongoing communication between all parties is crucial. Communicating with all parties involved in the project is a continuing challenge because involved parties are working in different locations, making regular, impromptu communication less likely.  E-mail and staff meetings have helped to make this less of an issue. It is helpful for the LHD to take a proactive role in organizing communication “check-ins” on a regular basis.  This helped program stakeholders in assessing the reasoning behind particular activities.  Questions that arose included: Does this activity help accomplish the project objectives? If not, is there a better way of accomplishing the same objective or is the activity an unanticipated but still important task to take on? The LHDs also took the lead in ensuring that partners focused on intended objectives and did not spend energy on extraneous activities that were not important to the program. 

Communication with the students who utilize the services is also important.  Portland staff have recently been trained on motivational interviewing and will incorporate these new skills into the program.  They believe this will increase their ability to help students make and sustain lifestyle changes.

Direct youth involvement in project development and implementation helps develop effective programs.  Portland stated that “Youth investment is a key to success and giving young people the means to help shape and share accountability for services that are targeted to them… [it] seems simple on the surface, but demands commitment and energy from the service providers to make it happen.”  Stamford used youth to help develop the survey that was then distributed to 162 students to determine which students should be included in the HIV risk reduction groups.

The sites stressed that offering students incentives for participation helps to assure ongoing attendance in multi-session HIV risk reduction groups.  Without incentives, attendance is sporadic at best.  Additionally, for meetings during lunch, the sites used funds to cover the cost of pizza to reduce the  time spent by students needing to buy their lunch. 

Obstacles to Implementing HIV/STI Programs in Schools

Competing priorities between stakeholders can make it difficult to implement the program.  School systems are focused on educating students and have a set of regulatory guidelines distinct from the guidelines that bind school-based health centers. Health programs often remain on the periphery and health services can be fragmented and put into silos. However, integrating the services into the fabric of school improvement plans can be done if key decision-makers come together to create policy change.

Some high-risk students may never make it into the program and are difficult to reach.  Students may indicate that they are sexually active, but may not agree to get tested.  Other students may not identify themselves as sexually active even if they are engaging in high-risk behavior. Parents may opt not to enroll their children in a program or a faculty member may be unwilling to release the student from class to go to the health center.  Additionally, some school policies require students to visit the nurse’s office before going to the health center, adding an additional step that students must go through. Portland stated, “Students who gain access to us are provided with HIV/STI services, but they may have needed to negotiate a difficult path to get to us.”

Limited funding cycles make planning and implementing programs difficult.  By the time city or county governments are able to process grants and the LHD is able to finish planning, a large portion of the grant cycle may have passed.

Examples of Impact

The following anecdotal information from the sites provides insight into how the programs impacted the youth of Stamford and Portland.

  • A political refugee with very little knowledge about STI transmission or pregnancy risk had been engaging in high-risk behavior. The student was counseled and given information on HIV/STI and pregnancy risk. Fortunately, the student tested negative to all risks.
  • Other reproductive health medical ailments that were not HIV/STI or pregnancy related were detected at health centers and students were referred to specialists for follow-up care. 

    Multi-session HIV risk-reduction groups helped students concerned with making unhealthy choices because of peer influence. One young student felt that hanging out with a high school cousin who engaged in high-risk behavior affected her own behavior. The group helped the student in taking steps to remove herself from the high-risk group and to get involved in safer activities with a more positive peer group.

  • The sites reported that students often have a great deal of misinformation and fear about HIV/STI and pregnancy issues. The programs were able to slowly build trust and rapport with students.   Some students would only stay for a short visit initially, but gradually began to share more information with the counselors, such as concerns about not being able to concentrate on school work be cause of concerns about high-risk behaviors.
  • In one case, the LHD referred the student to additional services and helped the student address her high-risk behavior. The student that had been failing classes, but returned several months later to tell the HIV counselor that she had made the honor roll. Some students became regular visitors and come to the health center with all of their health concerns.  This allows the staff many opportunities to provide them with information on safer sexual practices as well as other health information. Students were very grateful to clinic staff for providing these services.
  • Some students that were engaging in risk behaviors were very scared of getting tested. They needed time with the counselor to get correct information and to address their fears so that they felt comfortable getting tested. Students may be so fearful that they fail to return for their results, but because the health centers are in schools settings, HIV counselors are able to reach the students to give them their results and counsel them on how to reduce their high-risk behavior.
  • One student had an ex-boyfriend that used injection drugs. Through the program, she realized her own risk from having intercourse with him. Group members and the HIV leader supported her in getting tested, and she was able to direct her ex-boyfriend to a needle exchange program.
  • Students in risk-reduction groups consistently expressed that the group provided them with a safe place to discuss what they learned in health class and personalize it to their own lives, as well as obtain accurate information. Students were also able to discuss racism and the role racism plays in their involvement in high-risk behaviors. Substance abuse, needing to feel “high,” and many other issues were also discussed.

Comments from Students on Why the Health Center is Important to Them

  • They answer my questions and they did a great job with the [HIV and STI prevention] class.
  • The education was VERY helpful.
  • They keep my personal feelings and stuff to themselves.
  • It is a quick and easy place to go for answers.
  • Gives us a safe place to go. It’s ours.
  • You helped me when I needed it most.
  • It’s important to me because they answer all the questions I have. They make sure my privacy is kept in a safe place.
  • Because I can come here every time that I have questions or need something and they help me.