Download Challenges to Providing Partner Services

MID-AMERICA STD/HIV PREVENTION
TRAINING CENTER
PARTNER SERVICES AND PROGRAM SUPPORT
NEEDS
ASSESSMENT
2007
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Introduction
Prior to 2006, needs assessments conducted for Part III of the Mid-America Prevention Training
Center (MAPTC) primarily involved the distribution of surveys to STD and HIV program
managers, HIV and STD partner services providers, and others who had previously taken
MAPTC courses. These surveys inquired about the topics that recipients would like to have
covered in trainings, the skills they thought should be taught, assessments of the trainings they
had attended, the potential usefulness of those trainings in performing their job duties, and
various other related topics. In 2006 the MAPTC Part III staff decided they needed more
detailed information on the challenges and associated training needs of STD and HIV programs
and individuals providing partner services across the Mid-America region. Therefore, in
collaboration with Research and Evaluation (R&E) staff at the Colorado Department of Public
Health and Environment (CDPHE), MAPTC Part III staff developed a plan for conducting a
needs assessment that relied on the use of qualitative methods such as one-on-one interviews and
focus groups to afford customers a greater opportunity to discuss these areas. Data gathering
began in 2007 and consisted of eight phone interviews and one in-person interview conducted
with program managers from across the region as well as five focus groups with disease
intervention specialists (DIS). One of the focus groups was conducted with seven Denver-based
DIS at CDPHE. Four focus groups were conducted via conference calls involving a total of 28
DIS from 17 different programs (see the list of participants on page 17). Participants in the
interviews and focus groups were asked about the types of partner services offered through their
programs, the knowledge and skills most needed to provide effective partner services, challenges
to providing those services and meeting program goals, current disease trends, safety concerns,
and training needs. A wealth of information was gained from these focus groups and interviews
and is summarized below.
Program Descriptions, Goals, and Challenges to Meeting Program Goals
The nine program managers were first asked to briefly describe their programs and the types of
partner services provided in their states. They were also asked about challenges to meeting
program goals. In Montana, there are no state or regional DIS. All STD and HIV partner
services are provided by county health nurses that provide HIV, gonorrhea, chlamydia, and
syphilis follow-up. The state relies mostly on referrals made by these nurses to get sex partners
in for treatment rather than referrals made by patients. One challenge faced by the Montana
program stems from the fact that these nurses have not been to ISTDI training, and, according to
the Montana manager, some do not seem to understand the importance of partner follow up.
Some nurses tend to have more success conducting STD as opposed to HIV investigations. This
is attributed in part to the greater stigma associated with HIV. Another major challenge
described for Montana is the difficulty in engaging American Indian populations in HIV-related
efforts because of the high level of stigma and concerns about confidentiality in their small
communities. HIV is not recognized as a priority in these areas where people have so many
issues to address. STDs, methamphetamine use, and injection drug use are all prevalent on the
reservations. Other challenges to meeting program goals for partner services in Montana are
related to distance, lack of funding, and less than optimal cooperative relationships with law
enforcement and corrections.
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In Missouri 17 DIS are employed by the state while others are employed by the cities of St.
Louis and Kansas City. St. Louis DIS manage gonorrhea and chlamydia cases and have recently
begun managing HIV cases. State DIS manage syphilis and HIV cases. Regional supervisors
decide when to follow gonorrhea and chlamydia, however the overall number of cases make
follow up on all gonorrhea and chlamydia cases prohibitive. STD cases for which there is no
treatment information are prioritized to receive DIS follow-up. DIS referral of partners is
preferred over patient referral. Challenges to meeting program goals include the failure of some
DIS to get partner information from many HIV positive clients and difficulties in motivating
people who have tested positive or have been exposed to syphilis and other STDs to seek
treatment and inform partners. This is coupled with a growing tendency for many clients to
resist sharing information with DIS. Another challenge pertains to health care providers telling
their patients not to talk to DIS.
In Kansas, five DIS work for the state and seven work at the county level. DIS follow syphilis,
gonorrhea, chlamydia, and HIV. DIS are stationed in clinics and manage gonorrhea and
chlamydia cases diagnosed at these clinics. DIS try to rely on patient referral of partners, but
then follow up on cases in which there is no evidence that the partner went for treatment. In two
counties, DIS deliver therapy to partners who need treatment. One challenge to meeting program
goals cited in the interview involves attempts to provide partner services to men who have sex
with men (MSM) who have a number of anonymous partners, although they have had some
success in following partners via the Internet. These challenges are mostly related to syphilis
cases in which half of the MSM clients have been previously diagnosed with HIV. Similar to
Missouri’s experience, health care and other providers have encouraged clients with HIV not to
talk to DIS.
The state of Minnesota also has a combined HIV and STD program. DIS manage HIV, syphilis,
gonorrhea, and chlamydia. Gonorrhea and chlamydia cases are assigned for follow-up when
there is no evidence that clients have received treatment. Provider (i.e., DIS) referral of partners
is preferred. Often there is insufficient information to verify treatment of partners referred by
clients. Health care providers are asked to obtain partner information from their patients. DIS
then follow those partners at the patient’s request. One of the challenges to meeting program
goals that was cited in the interview involves the reluctance of many clients to meet with people
from the government to talk about health problems. As in other states, many clients are MSM
with anonymous partners met over the Internet or in bars and clubs. People diagnosed with HIV
are more inclined to refuse partner services than those with syphilis, possibly due to the different
way the diseases are approached by DIS.
In Illinois, the state has separate HIV and STD programs. Two managers working within the
STD program provided information for this needs assessment. No DIS are employed by the
state. Most partner services are offered by DIS at county health departments. These DIS follow
syphilis, gonorrhea, and chlamydia cases diagnosed at local health departments. They also
follow cases diagnosed through private providers upon request, and in smaller areas follow all
cases. State staff provide trainings for these DIS and assist county workers during larger syphilis
outbreaks. Provider referral is emphasized over patient referral, especially with syphilis cases in
which DIS always try to elicit partner information and ensure notification. Illinois programs also
contend with the same challenge reported by other states in eliciting partners from clients who
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have anonymous partners met over the Internet or in bathhouses and clubs. Time constraints in
the clinics also make it difficult for DIS to pursue information on social networks.
The Cook County STD program follows cases of gonorrhea, chlamydia, syphilis, and chancroid,
and assists the HIV program in providing partner services when needed. DIS see clients at
clinics. Clients decide on whether a DIS or a client will notify partners. Clients often bring their
partners with them, or may schedule appointments for their partners. One challenge to the Cook
County program is the lack of timeliness in receiving positive results and the inaccuracy of
disease reports. Additionally, some providers are not complying with reporting regulations.
The Chicago program currently employs 23 DIS (down from 50) working within six clinics,
various hospitals, and the county jail. HIV and syphilis cases are assigned for follow up. In
some clinics DIS referral of partners is emphasized. When client referral is used, DIS attempt to
follow up with partners after three days if there is no evidence that those partners were notified.
The program has recently developed protocols for DIS delivered therapy for gonorrhea and
chlamydia for women of childbearing age and people with repeat infections, but those activities
have yet to begin. One challenge to the program involves a shortage of DIS, bureaucratic
complications holding up the hiring of new DIS, and DIS getting pulled into other projects such
as providing STD presentations to the public. As a result, some DIS are getting frustrated and
burned out. Managing cases involving MSM with anonymous partners has also been a challenge
to meeting program goals, although DIS have had success in providing partner notification over
the Internet.
In Colorado the state has a combined STD and HIV program that provides a full range of partner
services including partner notification, prevention case management, case analysis, sourcespread analysis, referrals, and STD, HIV, viral load, and HBV testing in the field. The program
attempts to follow all HIV and syphilis cases. DIS follow gonorrhea and chlamydia cases in
HIV positive men with pharyngeal or rectal infections and suspected LGV. The state employs
seven DIS and three prevention case managers. The state also contracts with the county health
department in Colorado Springs to provide partner services. Challenges facing the Colorado
program include a tendency for some DIS to emphasize client advocacy over locating and
notifying partners and difficulties in using STD/MIS to obtain accurate data on activities.
In Ohio there are 23 DIS working throughout the state who are employed at the regional level.
DIS follow HIV and syphilis cases. They are housed at local health departments and work with
clients diagnosed at STD clinics. They also follow up on disease reports from other sources. In
Ohio both DIS and client referral of partners are emphasized. A lack of available trainings
related to partner services was discussed as a challenge to meeting program goals. Also, some
DIS seem to lack the level of comfort deemed necessary to work with HIV positive clients. In
contrast, their approach to syphilis tends to be more committed due to the availability of
treatment that can arrest the disease process.
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Knowledge and Skills Necessary to Provide Partner Services
When asked about the most important knowledge and skills needed to provide effective partner
services, the importance of having a solid working understanding of the diseases followed by
DIS, primarily gonorrhea, chlamydia, syphilis, and HIV, was mentioned by over half of the
managers. Such knowledge included information on transmission, symptoms, complications,
and treatment that should be provided to clients and basic STD epidemiology. Other essential
knowledge mentioned concerned familiarity with local services to which DIS can refer clients.
The most commonly emphasized set of skills was that related to interactions with clients. Good
communication skills including the ability to relate to and develop rapport with a broad range of
people were mentioned as critical to being a successful DIS by the majority of the managers.
Related to this skill was the ability to effectively conduct interviews with clients, ask appropriate
questions, listen attentively, and provide client-centered counseling to help people identify their
risk behaviors and understand how to lower risk. Such skills also involved the ability to
motivate clients to consider changing behaviors and to give accurate and usable information
about their sex or needle-sharing partners. Several managers discussed skills related to
conducting disease investigations and being able to manage cases efficiently. Other skills and
attributes mentioned less frequently included: 1) a thorough understanding of confidentiality; 2)
knowledge of how to stay safe while performing field investigations; 3) cultural knowledge and
basic understanding of diverse lifestyles; 4) ability to write clearly; 5) ability to problem-solve;
6) having a positive attitude; and 7) having a sense of dedication to the work.
In focus groups, DIS offered many of the same responses related to necessary knowledge and
skills as did the managers, although the emphases were different. Essential knowledge for the
DIS included a good working knowledge of STDs and HIV, their manifestations and
complications, and the treatments available. Two groups also cited good understandings of
cultural differences and of the realities of people in various communities, a better understanding
of men who have sex with men, and a more thorough understanding of the drugs commonly used
by clients, their complications, and their effects on risk behavior. Participants in all five groups
discussed the importance of good communication skills in doing DIS work. Such skills included
the ability to: treat people with respect and not appear judgmental; communicate in ways
understandable to clients; break down barriers and develop rapport; understand people’s “lingo”
and admit when one does not understand; present information in a sensitive way; be openminded about people and their situations and lifestyles; deal appropriately with people of
different backgrounds; and assure the confidentiality of services. Participants specifically
discussed the need for good interviewing skills including the ability to ask good questions, to
listen effectively, to respectfully challenge clients about behaviors, and to motivate them to give
partner information. A different aspect of communication concerned the ability to work well
with other providers and relay to them the importance of partner services. Other skills
mentioned in two groups each involved the ability to effectively manage cases and to conduct
investigations. One DIS mentioned the importance of being able to deal sensitively and
effectively with situations that may cause difficulties for clients and to be able to ensure client
safety as it relates to cooperation with DIS.
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Learning and the Role of Trainings
When asked about the best ways to learn the necessary knowledge and skills to be an effective
DIS, all of the managers thought that trainings had a role to play, although there were differences
expressed in the nature of that role. One manager expressed that training can have a big impact
on preparing DIS for their jobs, depending on the effectiveness of the trainers. The majority of
the managers expressed that training is good for teaching people the basics about diseases and
about fundamental counseling and interviewing skills such as asking open-ended questions. One
mentioned that all skills and knowledge could be enhanced through trainings, yet most agreed
that training was insufficient to prepare DIS to do the job well.
Almost all of the managers stressed the importance of new DIS learning from those who have
been working in the field for a number of years. Shadowing (i.e., pairing a new employee with a
seasoned DIS or supervisor) was the most commonly suggested strategy for teaching DIS
necessary knowledge and skills. This gives the new DIS an opportunity to observe how to work
effectively with different types of people in different situations and in different areas. One
suggested that shadowing become a standard part of ISTDI. Another manager stressed how
difficult it was to provide opportunities for shadowing in rural areas because of a lack of trained
personnel. Many managers thought that the bulk of the learning took place on the job as DIS
learned by doing and then adapted techniques as they gained more experience. This would
involve being observed and evaluated initially and then periodically by supervisors. One specific
idea offered by a manager for learning on the job was for a new DIS to begin by working
gonorrhea and chlamydia cases and then working up to syphilis and HIV once they have gained
some experience. One manager stressed the importance of assuring good supervision for DIS in
which expectations are clearly laid out and close monitoring and feedback is ongoing. Another
method for acquiring some of the necessary knowledge and skills that some of the managers
mentioned was simply through studying, stressing that some of the basic information did not
need to be actively taught.
In all but one of the focus groups with DIS, participants discussed trainings as being useful in
teaching basic information about diseases and treatment as well as allowing new DIS to practice
talking to “patients” in simulated situations. However, by far, the most important ways to learn
the necessary knowledge and skills for doing DIS work was by watching more seasoned DIS do
the job and by doing the job themselves. Watching others helped them learn a number of
approaches and techniques for communicating with people in different situations and people
from various at-risk populations, including gay men and prostitutes. Some also mentioned how
they learned a lot from clients and others in the communities in which DIS work and from
exposure to different types of people and their issues. Most thought that the bulk of their
education came from doing the job. One participant stressed how you often do not know what
you need until you are confronted with it in the field. Another discussed how after you have
done the job for a while people get to know you, making it is easier to work with certain
populations. Another means of learning mentioned by one participant was getting to know the
clinics better, how they function, and how physical exams are performed.
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Challenges to Providing Partner Services
The DIS participating in the focus groups discussed a number of interrelated issues that pose
challenges to providing partner services in their areas. In all but one of the groups, participants
discussed difficulties related to engaging with clients. Some discussed problems of trying to
“sell” partner services to people and convince them to discuss their partners, especially when
clients have just learned that they have HIV and are distraught. It can be difficult trying to
express empathy and be sensitive to the needs of the client while also trying to provide risk
reduction counseling, elicit partners, and provide referrals. This can be especially problematic at
a clinic where a number of providers may be trying to talk to clients during the same client visit.
The participants stressed that many clients do not understand the importance of partner services
and often do not trust the process and the assurance of confidentiality. Gay men were said to be
especially hard to engage, often refusing interviews or refusing to discuss their partners. As
mentioned by some of the managers, this is aggravated by the fact that doctors, case managers,
and other providers in many areas often tell their clients that they do not have to talk to DIS,
refuse to give client information, give incomplete information, or delay sending reports. Some
participants also discussed experiencing difficulties in convincing young people who test
positive for gonorrhea and chlamydia to care about their health and to take STDs more seriously.
DIS participating in the focus groups also discussed the many difficulties associated with
locating people. In all of the groups participants talked about the prevalence of anonymous sex,
with clients claiming they have no locating information on their partners. This was especially
the case among MSM. With many people meeting partners over the Internet, even when clients
share the names and Internet addresses of their partners, those names are often aliases and the
addresses are often changed. The proliferation of cell phones also has made locating partners
difficult given that cell phone numbers are not listed and are frequently disconnected or changed.
Other locating difficulties mentioned were associated with clients who are homeless and those
who are drug users and/or dealers and are frequently in hiding. Another factor that the DIS in
the focus groups found challenging and discouraging concerned the proliferation of recalcitrant
behaviors and reinfections. Commonly mentioned were the high number of people who were
previously diagnosed with HIV and later acquired syphilis, gonorrhea, and chlamydia -- often
more than once. Many DIS expressed frustrations associated with seeing the same people get
STDs numerous times. Another frustration involved trying to get some MSM and many young
heterosexual clients to care about their health and take the messages about protected sex
seriously.
Focus group participants discussed a number of other challenges. One concerned difficulties
associated with having appropriate places to which they can refer clients. Clinics and other
services were said to be unaffordable for some and inaccessible either due to distance, rules and
protocols, age requirements, gender requirements, or long waiting lists. Some talked of times
when they finally convinced clients to go to clinics, but the waits were so long that clients often
left without being seen by a clinician. Some of the DIS in the groups were able to deliver
medications to partners of clients testing positive for gonorrhea and chlamydia. This greatly
alleviated some of the problems of getting people in for treatment. Most participants agreed that
this or partner-delivered therapy should be an option in all of the areas in which gonorrhea and
chlamydia cases are assigned for field follow-up. Other challenges to DIS work discussed in the
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groups included: 1) language and cultural barriers associated with working with immigrant
clients; 2) heavy workloads and cumbersome amounts of paperwork associated with DIS work;
3) poor supervision; 4) jurisdictional problems associated with working close to state lines; and
5) not being located in clinics. Distance was a very big challenge for DIS and their clients in
rural areas spread out over large geographic regions.
When asked about different challenges associated with working HIV as opposed to STD cases,
DIS participants discussed the different level and type of sensitivity needed to work with persons
recently diagnosed with HIV given there is no cure. They mentioned how an HIV diagnosis
usually had a much deeper emotional impact on people as well as the greater amount of stigma
associated with the disease. One participant mentioned that it was harder to gain trust with HIV
positive clients. Another mentioned that many clients still see an HIV diagnosis as a death
sentence. One participant said that she treated HIV and other STDs the same in terms of the
messages given to clients with the rationale that preventing STDs can also prevent HIV. Another
said that HIV got treated differently because CDC had always treated it differently, thus making
different outcomes inevitable. One DIS stated that he tended to be more aggressive with syphilis
patients in trying to elicit partners.
Disease Trends Posing New Challenges
When managers were asked about current disease trends that posed challenges to their programs,
almost all mentioned increases in the overall numbers of reported cases of HIV and other STDs.
In Montana the proliferation of methamphetamine use was especially highlighted as a factor in
the spread of STDs and HIV, affecting the risk behaviors of both gay men and heterosexuals and
complicating efforts to locate and notify sex partners. This was exacerbated by difficulties in
working collaboratively with law enforcement and corrections to get people tested and treated, a
lack of available substance abuse treatment and programs that work with people with addictions
around behavior change, and a lack of familiarity with drug using populations among some
partner services providers. In Missouri, increases in gonorrhea, chlamydia, and syphilis have
surpassed the capabilities of program staff to follow all cases. Some DIS did not have sufficient
training and supervision to deal effectively with syphilis cases and to motivate clients to get
treatment and provide partner information.
In Minnesota an important trend concerned the increased number of HIV cases acquired in the
U.S. among immigrant and refugee populations. This phenomenon has brought with it major
cultural challenges related to high levels of stigma, secrecy surrounding HIV, and more
traditional male and female roles. Also problematic have been associated language barriers and
lack of adequate interpreter resources for some affected populations. In Kansas, cases of
gonorrhea and chlamydia had also exceeded the capacity of DIS to follow up on the cases. In
Illinois, managers discussed the rise in chlamydia and syphilis cases and the need to analyze the
geographic and demographic distribution of those cases. They highlighted the need to develop
and implement appropriate prevention interventions targeting the most affected populations by
working in collaboration with communities. Chicago and Cook County managers discussed the
high rates of gonorrhea and chlamydia among young people between the ages of 15 and 24 years
and syphilis cases among African Americans. In Colorado, one trend highlighted concerned the
issue of comorbidity involving people living with HIV getting other STDs. Ohio had
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experienced a large increase in the number of HIV cases diagnosed among 13 to 24 year olds,
especially among MSM of color. This was particularly problematic given that many from this
age group were not familiar with the history of HIV disease and often did not grasp its
seriousness. They also tended to feel invincible.
The disease trend discussed most frequently by the managers interviewed was the high rate of
syphilis among MSM and the large percentage of syphilis cases occurring among men previously
diagnosed with HIV. Many of the cases were associated with anonymous sex occurring in
bathhouses, in parks, at sex parties, or involving the Internet and chat lines. Motivating men to
provide partner information had proved problematic. Many did not even agree to be counseled
by DIS, with some refusing based on advice from their doctors. DIS in the majority of the focus
groups also discussed the large number of syphilis cases in MSM and the high percentage of
those coinfected with HIV. In one group, the participants discussed how this was associated
with a high level of substance abuse, particularly crack and methamphetamine use among MSM.
The proliferation of anonymous sex among MSM seriously complicated DIS efforts to provide
partner services.
In two of the focus groups, DIS also discussed the increase in HIV cases among teenagers and
young adults both gay and straight, with the highest rates among young African Americans.
Other disease trends mentioned by participants in the focus groups included: 1) relatively high
numbers of neurosyphilis cases; 2) high rates of coinfection with HIV and HCV among injection
drug users with few treatment options; 3) the large number of people in rural areas who inject
methamphetamines; 4) HIV within immigrant populations and the associated complications for
partner services; and 5) the significant number of people who are already AIDS cases when they
first test for HIV.
Safety Concerns
Most of the program managers interviewed thought that the DIS staff were relatively safe while
conducting field investigations, and none discussed any serious incidents involving their staff.
Among the principal safety concerns associated with providing partner services discussed by the
program managers was that DIS often have to search for people who are drug users or who live
in areas where a lot of drug activity and associated violence occur. Three of the managers
mentioned dogs as a safety concern and also a factor in sometimes preventing DIS from being
able to approach people’s homes. For those working in areas outside of cities, some managers
expressed concern about DIS working alone in remote areas, especially given that
methamphetamine users and some farmers and ranchers often do not want to admit to sexual
activity. One manager discussed safety issues associated with DIS not being issued cell phones.
Another described complacency as a safety concern as some DIS become too comfortable in the
communities in which they work, and they fail to be vigilant.
Most of the programs had either formal or informal safety guidelines in place. One manager
expressed concern about their not having such guidelines in place. Four programs had provided
some type of safety instruction for staff that taught DIS how to detect problems. Most managers
stated that they encourage DIS to leave an area whenever they are not comfortable with a
situation or to take another DIS with them. Most also encouraged or required that field
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investigations be conducted during daylight hours. One manager mentioned that they encourage
DIS to visit some clients early in the morning before there is a lot of activity in a neighborhood
or before a drug-using client is likely to get high. Several programs issued cell phones to staff
and one program provided DIS with state vehicles. Two managers mentioned that office staff
kept track of the daily itineraries of DIS. Two others discussed supervisors’ periodically
observing staff while in the field as a way of ensuring that they are taking precautions. One
manager expressed that it is often difficult to balance safety concerns with getting the work done.
Overall, the DIS participating in the focus groups said that they felt relatively safe doing their
jobs but did have a number of concerns. Group participants expressed some of the same safety
concerns as those discussed by the managers, although their concerns and suggestions for
making the job safer were more numerous and more varied. Some of those working in urban
areas expressed concerns about some parts of the cities where much of their fieldwork is
conducted. Poorly maintained buildings in areas characterized by a lot of drug, prostitution,
gang activity, and violence can pose difficult situations for DIS trying to find people, especially
if they are working alone or in the evening. In rural areas, it is often even more difficult for DIS
to take someone with them, and many of the people they need to contact are gun owners.
Several of the DIS participating in the groups discussed how they are often dealing with people
at a very emotional time and that they are often trying to contact and recontact people who do not
want to talk to them. They expressed that one never knows when a client might become angry
and violent. Another safety concern discussed was that DIS in some areas are not issued cell
phones or they have calling plans that are impractical for the job. Concerns about dogs were
mentioned in two of the groups as were concerns about needle sticks when drawing blood in
non-clinical settings. In two of the groups it was also pointed out how easy it is to get
complacent about safety, to let one’s guard down, and to not think about safety until something
bad happens. Other issues thought to compromise safety somewhat included: harassment by
law enforcement, a dress code which makes DIS look more conspicuous in many neighborhoods,
and the use of one’s personal car.
Although some programs have formal safety policies in place, in many other programs the
guidance is informal. Many DIS said that they relied mostly on their instincts, and when they
were not comfortable with a situation they would leave or take someone with them to a particular
location. In all of the groups, DIS discussed various methods used for tracking their
whereabouts while in the field, and many programs had guidelines concerning the times of day
DIS should not be in the field. State cars were available to DIS in a small number of programs.
A few other programs had restrictions on transporting clients in private vehicles. One person
mentioned that the DIS in her program carry mace. Others mentioned using strategies such as
meeting clients in public places and parking in ways that allowed for easy exits.
The needs discussed by DIS to make their jobs safer included: 1) issuing cell phones with
practical calling plans to all DIS; 2) providing state vehicles for field work; 3) utilizing GPS
systems; 4) walkie-talkies; 5) more frequent use of tandem visits; 6) better “buy-in” from
providers and promotion of partner services to clients; 7) increased opportunity to see clients in
clinics; and 8) providing transportation for clients so that they can get to clinics or other locations
where interviews can take place.
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Training Needs and Effective Training Strategies
Managers. A great number of ideas came out of discussions with managers and DIS concerning
the trainings that should be available, topics that should be covered, effective strategies that
could be used in the trainings, and some overall comments about past trainings. One subject
discussed by half of the managers interviewed concerned the need for DIS to gain a deeper
understanding of the populations with which they dealt most frequently. To the managers,
cultural competence training should result in a better understanding of cultural differences,
ideologies, lifestyles, and behavior patterns and should be integrated into dealing with people
from other countries, people from various ethnic groups, drug users, and gay and bisexual men.
The need to better understand, develop rapport with, and engage gay men in disease prevention
efforts was especially highlighted. Cultural competence training should also assist DIS in
gaining a better understanding of their own biases and how to keep them from being exhibited
when working with clients whose lives may be very different from their own. Two managers
discussed the need to build people’s capacity to talk to clients about sex with a high degree of
comfort. One manager suggested that cultural competence trainings needed to be relevant to the
places where DIS work and the populations with which they work most frequently. Another
thought that such training needed to be tied more closely to DIS work. This would necessitate a
more direct linkage between cultural information and its impact on disease transmission as well
as how to achieve the best outcomes given the specific challenges DIS confront.
Another training-related topic discussed by half of the managers concerned the need to keep DIS
motivated and focused on disease prevention. Some discussed burnout while others mentioned a
tendency for DIS to concentrate more on client advocacy rather than on partner services. Some
managers suggested a training that involved reinforcing the importance of such services and the
associated goals, objectives, and processes such as eliciting partners, locating them, and getting
them tested or treated. Managers also emphasized the need to build interviewing skills and
develop sound techniques for motivating clients toward providing partner information and
making behavior changes. A common suggestion offered by the majority of the managers
concerned the need to offer more advanced trainings and updates for seasoned DIS as well as
trainings on related subjects that can enhance their abilities to do their jobs such as behavior
change, motivational interviewing, prevention for positives, mental health, and substance abuse.
There were a number of other suggestions for training topics, each offered by one or two of the
managers. These included: 1) more information on reportable STDs, other STDs such as HSV
and HPV, and related diseases such as HCV; 2) basic epidemiology; 3) supervision, with a focus
on ensuring disease prevention; 4) surveillance and data management; 5) management of cases;
6) making sound and effective referrals; 7) using the Internet to notify partners of exposures; 8)
group facilitation and presentations; and 9) safety.
Managers also offered some ideas for effective strategies that could be used in trainings for DIS.
Two people made the general comment that trainings should be interactive and include role
plays. One manager suggested that DIS could brainstorm all of the reasons why clients might
refuse partner services or withhold information and then discuss as a group how to resolve
problems and reduce barriers. A similar suggestion involved DIS reviewing cases with a number
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of errors and fixing them together. Two of the managers discussed how one should not try to
cover too much in a training, but provide shorter trainings on single subjects such as interviewing
techniques and ways for using various techniques in different situations. One suggested training
on a subject for a couple of days followed by observation and working a case. Another manager
emphasized the need for a gay man to teach trainings on providing partner services to MSM.
One also suggested that some topics could be taught through distance learning to increase
availability and save time. Other suggestions from the managers concerning trainings included:
1) increasing the availability of trainings in more locations, including locations more accessible
to DIS working in outlying areas; 2) improving advertising of the course schedule with better
descriptions of the courses offered; and 3) tailoring trainings to the people attending the trainings
and the programs they represent.
DIS. Not unexpectedly, most of the information on the training needs of those providing partner
services and on effective training strategies came from the DIS who participated in the five focus
groups. The needs discussed can be divided into three general categories: improving interview
outcomes, filling information gaps, and relieving the emotional burden associated with
performing DIS work.
The first category involved trainings that could help DIS improve their interviewing skills and
add to their toolkit to improve outcomes in a number of situations. A few of the suggestions
offered included honing basic interviewing skills such as focused listening, asking open-ended
questions, and motivating clients to provide information or seek treatment. Some suggestions
concerned adapting interviewing strategies in various situations, such as how messages,
questions, and follow-up should vary by disease; disease stage (e.g., acute HIV versus longstanding infections and AIDS diagnoses); or different situations such as when dealing with
recalcitrant clients, repeaters, clients with anonymous partners, or clients in domestic violence
situations. Another set of suggestions involved dealing with clients with varying attitudes and
personalities and dealing appropriately and sensitively with clients of different cultural and
language backgrounds. Rather than general cultural competence training, DIS were more
interested in gaining competence related directly to providing partner services. Learning to
better understand, engage, and elicit information from MSM clients was especially needed given
the relatively high level of resistance typical of this population across the region. The need to
learn to better provide services to other populations such as homeless people and transgenders
was also cited.
In every focus group participants discussed the need for various types of information that would
enhance their ability to do their jobs. Recommendations included short refresher courses, basic
and sometimes more in-depth information on relevant subjects, and updates on new information
to better prepare DIS for answering clients’ questions. One set of suggestions involved the need
to increase DIS knowledge about: 1) reportable STDs such as gonorrhea, chlamydia, and
syphilis and related disease processes, complications, and treatment guidelines; 2) how to talk to
people about the different diseases, and terminology that various populations may use for the
diseases; 3) HIV, its various stages, and related issues such as viral loads and CD4 counts; and 4)
related diseases such as hepatitis, TB, herpes, and HPV, including information on where to refer
clients and how these diseases are related to HIV. DIS from all over the region expressed a need
for updates including new information about STDs and HIV, new technologies and protocols,
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new medications and drug interactions, and new disease trends. DIS offered that it was not only
important for experts to relay this information to DIS, but to also engage DIS in discussions
about how counseling messages should change or how follow-up with clients should be different
based on the new information. In one group participants discussed how in-services should be
tailored to the geographic area and specific programs.
Other training topics requested by DIS in one or two focus groups included: 1) enhanced
investigation techniques including how to tailor investigations and use different tools with
different people; 2) more information on the drugs that people use and how they affect behavior;
3) communication skills and how to adapt these in different settings and with different types of
people including clients, health care providers, and coworkers; 4) partner relationships and how
they may be affected by partner services; 5) safety; 6) effective use of STD*MIS; 7) DISdelivered therapy and how to facilitate its integration into programs; 8) official policies and
regulations governing the delivery of partner services; 9) conversational Spanish; 10) solutionfocused therapy; and 11) advanced skills for seasoned DIS. In three of the focus groups,
participants discussed the need to be able to address the particular stress and burnout associated
with providing partner services. They emphasized that providers of such trainings needed to be
people who were familiar with the job. DIS expressed a need for help with how to avoid letting
the job become consuming or discouraging, how to handle the heavy workload, and how to
handle vicarious trauma. They also expressed the need to talk to others who understand the job
and its toll.
A large number of training strategies were suggested by DIS participating in the focus groups.
By far the most commonly discussed strategy in all of the groups involved DIS being able to
discuss their work with each other and share experiences, ideas, issues, challenges, and
strategies. This would give DIS an opportunity to review difficult cases and situations and gain
feedback from others on different ways to approach clients and confront barriers in diverse
situations and areas. This would involve discussing “real-life” situations, which they saw as
more practical and helpful than discussing simulations. Such discussions would also provide an
opportunity to learn from more experienced DIS about different interviewing styles and different
approaches to eliciting partners. Discussions among DIS working in different locations were
viewed as valuable to increasing their understanding of different populations and identifying
ways to work with them as well as a good opportunity to network. This strategy was also seen as
a way to motivate DIS and reinforce the value of DIS work. Related to this, one person
suggested a DIS exchange between states to learn what the work is like in other settings.
Another suggested a DIS conference or sessions for DIS at STD and HIV conferences.
Other suggestions for training strategies included: 1) interactive activities such as role plays; 2)
discussions with experts on topics such as why people do not disclose HIV status and related
issues; 3) group discussions for identifying ways to handle particular cases or scenarios; 4)
addressing scenarios relevant to the populations most being served in particular regions (e.g.,
MSM, immigrants from various countries, etc.); 5) providing regional statistics; 6) field trips to
places such as bathhouses or crack houses; 7) providing feedback on simulated interviews; 8)
showing videos of interviewing sessions and then critiquing them as a group; and 9) dealing with
actual case studies and picking them apart as a group. Ineffective strategies included the
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excessive use of lectures, long sessions, pre and post tests, and having managers go to trainings
and then attempting to relay information to staff.
Other insights offered by the DIS included the need for program specific trainings in which all
DIS hear the same information at the same time; the need for more local offerings or ways to
access trainings via the Internet or through teleconferencing; the need to provide trainings about
DIS services and their importance for disease prevention to health care providers, case managers,
and others who deal with clients living with HIV; and the need to tailor trainings to individual
DIS and program needs. DIS also suggested that trainers be DIS or former DIS who have
recently provided partner services. They also suggested that trainings about specific populations
be taught by people from those populations. They especially recommended that trainings about
MSM be taught by gay men.
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SUMMARY AND RECOMMENDATIONS
The overall training-related goal highlighted by both the managers and the DIS participating in
this needs assessment was for DIS to access knowledge and skills that would improve the
outcomes of partner services. One common theme that emerged from the interviews and focus
groups was the desire for additional tools and practical strategies to use when working with
clients. DIS expressed that they wanted updates and in-services to gain new knowledge so that
they could better explain critical information to clients and answer their questions more
effectively. DIS also wanted to learn practical ways to incorporate new information into the
provision of partner services. In other words, as new technologies are developed and
incorporated into partner services activities or better understandings of reportable STDs and HIV
come to light, DIS wanted to know how these changes in technologies and enhanced knowledge
should influence their approaches and the counseling messages they provide to clients.
Another theme concerned the need for a variety of strategies to use when working with the
diversity of people DIS encounter and their differing life circumstances. Managers and DIS
alike saw the need to learn many different approaches that DIS could adapt in their work. They
suggested that trainings should include discussions of how to engage and motivate people from
diverse cultural backgrounds as well as people of different ages and sexual orientations.
Trainings should cover strategies for working with differing personality types or with people
experiencing different emotions such as anger, fear, suspicion, or grief. Trainings should also
cover various ways to work with people with addictions, those with emotional problems or
mental illness, those exhibiting recalcitrant behaviors, and those who are homeless.
Additionally, trainings should distinguish the most important messages to give to people
depending on the diseases they contract such as gonorrhea, chlamydia, syphilis, and HIV or the
relevant stages of those diseases. Possibly the biggest need expressed was for mechanisms to
help DIS better understand, engage, and motivate MSM to accept partner services or make
behavior changes to lower risk.
Perhaps the most prominent theme coming from the interviews and focus groups was the
importance of DIS learning from each other and having the opportunity to share experiences,
challenges, ideas, and approaches to providing partner services. DIS thought that trainings
should allow for group discussions and provide opportunities for DIS to work together on
identifying the best approaches and strategies to use as they analyze actual cases and field
situations. DIS also expressed a need for the opportunity to talk with others who understand how
difficult and stressful providing partner services can be and to learn ways to alleviate job-related
stress.
As mentioned in the introduction to this report, this needs assessment was designed to elicit
detailed information on the challenges and associated training needs of STD and HIV programs
and individuals providing partner services in the Mid-America region. However, many of the
expressed needs and associated recommendations that surfaced during the interviews and focus
groups went beyond the purview of the MAPTC and included recommendations more pertinent
for STD and HIV programs and the CDC. Therefore, the following sets of recommendations are
presented in three overlapping categories: those directed to the CDC, those directed to programs,
and those directed to the MAPTC. Some recommendations are listed in more than one category.
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Recommendations to CDC
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Improve access to advanced trainings for DIS, including the Advanced STD Intervention
(ASTDI) course.
As part of the ASTDI course, include advanced communication skills and enhanced skills for
engaging and motivating clients from diverse backgrounds and differing life circumstances.
Incorporate group exercises in the course that involve collaboration in the analysis and
correction of cases. Encourage participants to share examples of difficult cases confronted
by DIS during actual field investigations and focus discussion on those examples.
Support the efforts of the MAPTC to improve access to trainings by DIS from across the
region through increased funding for enhanced training efforts and for travel expenses for
DIS to attend trainings more frequently.
Develop a mechanism by which DIS from across the country can communicate with each
other and share ideas and information. This could take the form of a website that includes an
electronic newsletter relaying new information pertinent to DIS work and a “blog” or “chat
room”. Monitor the information being shared to ensure accuracy and confidentiality.
Include a focus on partner services at the national STD conference as well as a forum for DIS
to discuss their work and share information and ideas.
Develop national standards and guidance on the use of the Internet as a tool in providing
partner services.
Continue to disseminate guidance and provide technical assistance concerning the
implementation of expedited partner therapy (EPT); disseminate information about how state
and local programs have successfully integrated EPT into DIS work.
Provide national guidance for “shadowing” (observation of experienced DIS) as a standard
part of training new DIS. When necessary, provide opportunities for DIS to travel to other
areas if shadowing opportunities are not practical/available locally. Establish a national
mentoring program in which DIS can spend time learning through observations of and
discussions with more experienced DIS specially trained as mentors. Include shadowing as a
standard part of ISTDI.
Incorporate information about PCRS into Prevention Training Center Parts I and II to
increase health care and other service providers’ understanding of the nature and benefits of
partner services. Encourage providers to relay this information to their patients/clients and to
support client participation in partner services activities.
Support the development of a course designed for those who manage partner services
programs and for DIS supervisors. Provide guidelines and develop skills for supervision,
mentoring, quality assurance, and developing and relaying clear standards, expectations, and
guidance for service provision and promotion of public health.
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Recommendations to Programs
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Develop, review, and revise, as necessary, standards of practice to ensure consistency with
local laws and regulations (e.g. those concerning confidentiality, Internet use for partner
services, recalcitrant behavior, etc.). Ensure that DIS are well trained on these standards of
practice and laws and how they influence partner services.
Emphasize the use of the Employee Development Guide to provide standard knowledge to
DIS. For essential information that does not involve skill building (e.g. disease-related
information), provide this to DIS through means other than trainings.
Provide periodic in-services and updates to DIS on information relevant to partner services.
Identify written sources of relevant information, and improve DIS access to such
information.
Provide clear and specific guidance to DIS on how interviewing techniques and counseling
messages should be adapted for specific situations. For example, ensure that all DIS
understand the expectations and know the particular counseling messages to relay in
interviews with recalcitrant clients, those with acute HIV infections, those facing potential
partner violence, etc.
Develop and implement plans for communicating with providers to improve their
understanding of partner services and engage them in promoting partner services among their
clients. Play an active role in “selling” partner services to health care providers, communitybased organizations, AIDS service organizations, gay and lesbian community centers, etc.
Examples of means to promote partner services among providers include: 1) distributing the
PCRS Primer Video (developed by the MAPTC in 2006) to health care and other service
providers likely to serve individuals at increased risk for HIV/STD; 2) designating a liaison
to providers to clarify the nature, purpose, and benefits of partner services and encourage the
promotion of such services to clients; and 3) providing partner services in-services to
provider groups.
Ensure opportunities for new DIS to shadow more experienced DIS so they can observe
people modeling the skills they will later utilize when providing partner services.
Develop and implement mechanisms for motivating DIS and reinforcing the importance of
the work they do. Examine and, when necessary, adapt program strategies for developing
DIS as public health professionals and for communicating and valuing the importance of DIS
work in protecting the public’s health. Examine how DIS burnout and job-related stress are
being addressed. Implement strategies that support DIS in the work they do.
Clarify the extent of the role of DIS in supporting behavior change among individuals
receiving partner services. Given the brief time DIS spend engaging patients and partners,
the outcomes of partner services alone may be limited to the identification of high-risk
individuals, the introduction of risk-reduction plans, and referrals to more intensive
interventions.
Develop a local listing of agencies to which DIS can refer clients and ensure that DIS are
very familiar with those resources.
Develop mechanisms for partnering with public health professionals working in related fields
(e.g., adolescent health, women’s health, etc.) and with locally affected communities
(including MSM and immigrant communities) to address barriers to providing partner
services. When possible, include people from affected communities and bilingual people on
staff.
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Ensure that programs have written guidelines to assure the safety of DIS. Provide safety
trainings tailored to local circumstances. Establish safety protocols and specific guidance
concerning their utilization. Allocate resources based on local circumstances to ensure the
safety of DIS. Ensure that all DIS have cell phones with calling plans suitable to the work.
Recommendations to the MAPTC
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With the support of CDC, develop a course for those who manage partner services programs
and DIS supervisors. Provide guidelines and develop skills for supervision, mentoring,
quality assurance, and for developing and relaying clear standards, expectations, and
guidance for service provision and promotion of public health.
Redesign trainings pertaining to MSM to better reflect the complex context of high-risk
behaviors and barriers to providing services to populations of MSM.
Redesign cultural competence trainings so that they are more closely related to providing
partner services. Such courses should be designed to improve participants’ understanding of
cultural differences; assist participants in examining their biases and decrease the negative
impact of personal biases on the provision of partner services; and provide skills needed to
effectively engage people from different countries and ethnic groups, drug users, and MSM
in partner services activities.
Review current strategies for the marketing and packaging of MSM, cultural competence,
and mental health/substance abuse trainings to enhance access by DIS throughout the region.
Integrate/reinstitute more hands on, practice, and shadowing activities into course offerings.
Where appropriate, incorporate strategies for developing DIS competence and comfort
related to discussing sexual issues with clients.
Design new situations for use in case studies and role-play exercises as suggested in the
interviews and focus groups. When possible, utilize examples of situations experienced or
suggested by participants in the trainings.
Enhance the problem solving, motivation, and assertiveness pieces in training courses.
Enhance communications and listening practice in training courses.
Improve advertising of the course schedule and include better descriptions of the courses
offered.
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Acknowledgements and List of Participants
The Mid-America Prevention Training Center and the Research and Evaluation Unit at the
Colorado Department of Public Health and Environment would like to thank the following
people for their participation in the interviews and focus groups and for help with recruiting
participants.
Mandy Anderson – Indianapolis
Iris Berry – Cook County
Janell Bezdek - Denver
Linda Bodick – Montana
Susan Bradshaw – Missouri
Dan Brooks – Indianapolis
Althea Bruce – Colorado
Shelley Crowson – Topeka
John Crevinston – Illinois
Derek Coppedge – Kansas
Shaun Cosgrove – Denver
Kenya Davis – Detroit
Ingrid Denney – Missouri
Rick Edwards – Chicago
Pam Grayson – Kansas City
Jessica Hubbard – Indiana
Doug Johnson – North Dakota
Tameeka Johnson – Chicago
Alicia Jones – Kansas City
Laurie Kops – Montana
Danny Lopez – Denver
John Lucero – Wichita
Paulette McClure – Ohio
Yesenia Mendez – Denver
Pier Morris – Detroit
Kenny Muller – Illinois
Brett Oakland – South Dakota
David Owens – Topeka
Nena Patterson – Chicago
Tanisha Pettus – Columbus
Tina Radford – Columbus
Ed Ranier – Illinois
Jesse Saavedra – Minneapolis
Steve Schletty – Minnesota
Maria Sifuentes – Denver
Shamika Smith – Cook County
Briana Sprague – Denver
Beth Tackitt – Wichita
Karen Thorsten – St. Louis
Thuan Tran – Minneapolis
Vanessa Vann – Milwaukee
Faith Wesley – Detroit
Helen White – Milwaukee
Nancy Wolff – Denver
Jason Ybarra – Wichita
We would also like to thank some other individuals for their assistance in making these
interviews and focus groups possible. They include:
Joni Finley - Columbus
Sandra Johnson - Detroit
Rob Johnston - Wyoming
Aaron Mettey - Indianapolis
Stephanie Montgomery – Cook County
David Morgan – South Dakota
Dawne Rekas - Indiana
Darlene Turner-Harper - Milwaukee
Kim Weis – North Dakota
This assessment can be downloaded from www.maptc.com
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