Astute healthcare-related nonprofit and public agency managers who follow grant opportunities have probably noticed how many of those grant opportunities use specific, somewhat coded language to express whatever it is that they want (read a lot, and you’ll start to see patterns in RFP verbiage). We’ve written many modern HIV prevention and education grant-funded programs, and, consequently, we’ve gotten very good at designing how those programs should be pitched to funders—the most common being the Health Resources and Services Administration (HRSA). Still, HRSA Notices of Funding Opportunity (NOFOs) are often opaque about how exactly the applicant is supposed to provide services and what precisely the applicant should do. The purpose of being opaque may be so that applicants can signal their underlying competence and knowledge.
Many HIV-services programs can be divided into two categories, although the categories can overlap: prevention/education and treatment. We’re going to focus on the former, at least in this post, though some grant-funded programs will ask for both components. A typical grant-funded project purpose for a program designed to provide prevention and education is something like “reduce HIV transmission via outreach and engagement.” The target population will usually be persons at high risk for HIV/AIDs, but who are known to not be HIV+. Federal funders like vaguely bureaucratic terms like “persons” over more human terms like “folks;” the more bureaucratic and less human a proposal sounds, the more funders will typically like it.*
The applicant agency should typically propose a project that will use peers of the high risk population—that is, people who are “culturally and linguistically like the target population”—to do outreach, engagement, and education. A common term for such a position is a “Community Health Worker” (CHW). CHWs are often paired with Registered Nurses (RNs) or similarly licensed clinicians: the CHW goes out, finds the target, high-risk population, talks to members of the target population, and gets them to be tested.
This involves some combination of on-the-spot rapid HIV testing to see if the high-risk person might already be positive, along with education and the like if they’re not. Education includes things like “why using PrEP is a good idea,” “how to avoid sharing needles,” etc. The CHW will encourage the at-risk person to reduce risky behaviors (e.g., sharing needles, or unprotected sex with multiple random partners, and the like). This kind of outreach effort is sometimes done with a mobile outreach unit, often a van, that’s owned/leased and operated by the applicant. In some grant programs, it’s possible to buy the van with grant funds, but, even when the van isn’t covered, leasing and operating costs (e.g., gas, maintenance, insurance, etc.) should be eligible grant costs.
In addition to culturally and linguistically street-based education and rapid HIV testing in the outreach van, CHWs try to get who are found to be HIV+ via rapid test a follow-up laboratory confirmation test. If the lab test confirms the person is HIV+, the CHW tries to get help that person get into treatment. Persons who are positive should in particular be targeted for entry into services.
But funders usually also want all high-risk persons who are engaged by the team to establish a medical home and, for HRSA, this means at a Federally Qualified Health Center’s (FQHC). In the real world, many FQHCs aren’t excited by the prospect of new, high-risk, and difficult-to-serve patients, but HRSA and other funders want to hear that this is going to happen.
HIV+ persons obviously need care, and consistent care, both to ensure their own safety and to reduce the likelihood of community transmission. Modern, consistently applied HIV treatments haven’t, to our knowledge, been shown to conclusively, completely, continuously prevent HIV transmission, but they can make the virus nearly undetectable in the body, which likely reduces transmission (if there is evidence one way or another, please cite it in the comments). PrEP in the high-risk, but uninfected population, in combination with effective, consistent usage of anti-HIV drugs in the infected population, is a potent combination to reduce HIV prevalence, which is why almost all modern HIV-prevention programs want this approach, whether they say so directly or not.
The peer-to-peer outreach approach, in which the organization hires CHWs with the “street cred” to engage the target population, ensures that the target population is more likely to accept some level of engagement, education, and behavior changes to reduce risks. The peer positions receive training in HIV and how HIV prevention works, and then go into the community to seek high-risk, hard-to-reach persons. Applicants should also propose more general outreach efforts focused on social media. Virtually all targeted persons will have smart phones; even most homeless people do, today.
The approach we’ve discussed above can be described in more detail or less detail—for example, what specifics will the educational effort cover? How long will CHWs seek to talk to each person who is reached out to?—but the basic structure has been consistent for years.
* I observe the rules and principles; I don’t make them.
