Evidence of Success - Northwest AETC Service Area: Alaska, Idaho, Montana, Oregon, Washington

Northwest AETC

Illustration: Increasing the Capacity for HIV Care on Reservations

The NW AETC Minority AIDS Initiative Program has implemented innovative approaches to working with American Indian and Alaska Native (AI/AN) communities in its five-state region to increase access to quality HIV care and treatment that is also culturally appropriate. The Tribal B.E.A.R. (Building Effective AIDS Response) Project (TBP), a collaboration with the Salish Kootenai College in Montana and the South Puget Intertribal Planning Agency in Washington, is one NW AETC program that specifically focuses on building capacity within tribal health care systems to provide quality care to HIV-infected tribal members. The TBP program offers the opportunity for tribal clinics to enter into long-term relationships with TBP staff whereby the clinic's HIV and sexually transmitted infection training needs are assessed and longitudinal NW AETC training is provided. Training is provided across a broad range of topics in the HIV continuum of care and employs multiple training methods, including didactic, skill-building, hands-on clinical experiences, and combined on-site and distant clinical consultation services.

Prior to TBP involvement with tribal clinics, tribal providers often were unaware of HIV cases in the community. Even if they were aware, they were unlikely to be caring for infected patients. Several factors contributed to this reality: an absence of HIV counseling and testing services, providers with limited knowledge and experience in conducting risk assessments or providing HIV care and treatment, issues related to stigma, and confidentiality concerns. After TBP training and consultation regarding these and other related care issues, providers demonstrated statistically significant increases in levels of knowledge, skills, and positive attitudes about providing HIV care and treatment. An HIV-infected American Indian stated, "I think it is very important for health care workers on the reservation to get training and education and some kind of handle on how to deal with Natives and HIV so Native people can seek treatment within their own communities so there's a better chance of healing and living with HIV instead of dying with it?"

Outcomes

Immediate/Short-term:

	Increased percent of tribal providers who agreed (73%) or strongly agreed (78%) that they were confident in their capacity and more willing to work directly with people living with and/or at risk for HIV.
	Enhanced provider knowledge about and skills in providing HIV care and treatment.
	Increased awareness among providers of the impact of HIV among American Indians.
	Initiated HIV clinical care in one setting.
	Developed confidence and comfort of clinicians to provide care in telephone consultation with NW AETC Medical Program Director.

Mid-term/Long-term:

	Established on-going access to expert consultation services.
	Created long-term relationships between tribal clinics, NW AETC/TBP staff, and HIV care experts.

Montana Local Performance Site

Illustration: Increasing Access to Care in Rural Eastern Montana

Kathy Hall, PA-C, is a primary care provider in Billings, Montana. She received extensive NW AETC training in the care and treatment of HIV-infected patients and is now considered one of the HIV care experts in Montana. She provides care for HIV-infected patients at a RWCA Title III-funded clinic in Billings. Following her training with the NW AETC, Ms. Hall became the clinical educator at the NW AETC LPS in Montana. The vignette presented below involves a patient that Ms. Hall began seeing at the Title III clinic.

In October 2000, a 20-year-old woman, newly diagnosed with HIV, could not get HIV care in her local community; she had to travel 220 miles from her home to the Title III-funded clinic where Ms. Hall worked. During one visit, the patient confided that she had disclosed her HIV status to friends, and, when people in the community learned of her HIV status, she experienced discrimination, threats, and the loss of her job. She also reported that during a routine visit to her local provider for a minor procedure, the nurse and physician entered the room wearing protective caps, masks, gloves, and surgical gowns. The patient was upset and embarrassed. She vowed never to enter that clinic again, further decreasing her ability to get care in her home community.

Subsequently, Ms. Hall contacted physicians in the patient's community. She asked them to complete an HIV care and treatment education needs assessment. The patient's physician responded that he wanted to learn more about HIV in order to assume some responsibility for care of HIV-infected clients. Ms. Hall arranged for the physician to participate in clinical training at her Title III-funded clinic that was serendipitously scheduled on a day when the physician's HIV-infected patient was being seen. During the clinic visit, the patient agreed to be seen by the physician and said she was happy that her physician was there to learn about HIV. Ms. Hall now provides on going consultation to the physician to co-manage HIV-infected patients. She has also educated the community about HIV transmission to help dispel community-held myths and preconceptions.

Outcomes

Immediate/Short-term:

	Assessed HIV education needs in local community.
	Provided clinicians with learning opportunities.
	Increased knowledge and sensitivity of provider and staff in providing care to HIV-infected patients.
	Increased awareness in community about myths and misconceptions associated with HIV transmission.
	Established effective lines of communication between patient and physician.
	Increased physician ability to teach staff about HIV.

Mid-term/Long-term:

	Established co-managed patient care in consultation with physician assistant.
	Initiated more appropriate medical care in community.
	Decreased cost and inconvenience of care for patient with less travel to Title III clinic.
	Continued opportunities for physician to learn about HIV care through support and ongoing consultation with NW AETC/LPS staff in Montana.