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The Pacific AIDS Education and Training Center
Uses a Surprising Variety of Operational Strategies

Taking It to the Frontlines

Outsourcing…spin-offs…systems implementation…alliance management…globalization. They aren’t just corporate buzzwords from the pages of the Wall Street Journal. These are some of the effective strategies used by ARI affiliate the Pacific AIDS Education and Training Center (PAETC) to fulfill its mission. One of 11 regional centers of the national AIDS Education and Training Center (AETC) program, the PAETC has a mandate to provide AIDS treatment–related training, education, and information to health care providers across California, Arizona, Nevada, Hawaii, and the six U.S.-affiliated Pacific Jurisdictions that include Guam and America Samoa. To pursue its mission, the PAETC operates using an extremely decentralized model and applies many techniques familiar to global corporations.

Linking Local Experts to HIV Care Providers

You won’t find any classrooms among the downtown San Francisco offices where the PAETC shares a floor with the ARI and the Center for AIDS Prevention Studies (CAPS). Educational outreach to AIDS treatment providers means truly reaching out into local communities within its large territory. Almost all PAETC training is outsourced to local AIDS experts. “We have 15 sites in our four states that perform the training education in their local communities,” explains Mona Bernstein, deputy director of the PAETC. They are the experts on the local epidemiology and their local healthcare delivery system.

Michael Reyes, who has directed the PAETC since 1992 and co-directs the International Training and Education Center on HIV (I-TECH), adds, “We want the clinicians of each region to be turning to their local thought leaders about what they should be doing and practicing. It doesn’t make sense for the clinicians in Reno or Las Vegas or Tucson to turn to San Francisco for all the expertise.”

Some of the 15 PAETC “local performance sites,” as these training centers are called, are based at major medical schools, including UCSF, UCLA, UC San Diego, and the University of Southern California; others operate from community-based organizations in smaller centers.

National Clinician’s Consultation Service consultant Dr. Amy Kindrick with a participant at a recent PAETC Pacific Clinicians Conference.

The PAETC’s decentralized model makes sense, according to Janet Myers, who as director of the AETC National Evaluation Center has a comprehensive perspective on how the PAETC operates compared to other regional AETCs. She says, “The PAETC is the largest of the AETCs. Letting its local performance sites create their own homegrown programs is a very appropriate way to reach out to the extremely broad range of communities in its states and within the Pacific Jurisdictions.”

Who Uses the PAETC?

Who are their clients, those HIV care providers who benefit from PAETC training and information services? They are physicians, nurses, nurse practitioners, pharmacists, and oral health specialists serving primarily uninsured patients covered by the federal Ryan White HIV/AIDS Program.

Bernstein fleshes out the picture, adding, “They are in different kinds of settings. They might be specialty clinics, they might be primary care settings, community health centers, hospital clinics, city clinics. That is our primary audience. Our secondary audience is what I would call mid-volume or low-volume providers. Those are people who are not necessarily HIV specialists, but they are seeing infected patients, and maybe they are the only people in town doing that. They might be practicing family medicine or internal medicine and seeing these patients in their own private practices.”

Supporting from the Center

The PAETC used a spin-off strategy to keep small and focused, yet still provide a clinical safety net to supplement its local expert trainers. The National HIV Telephone Consultation Service, or Warmline, provides expert clinical consultation for HIV care providers on the frontlines. Originating within the PAETC, its operation was spun out in 2000 when the National HIV/AIDS Clinicians’ Consultation Center (NCCC) was established at San Francisco General Hospital. NCCC now has its own funding to provide that service nationally, together with two additional phone support lines: the PEPline for Post-Exposure Prophylaxis advice and the Perinatal Hotline.

On the training front, the PAETC strives to support its educator-subcontractors at local performance sites by leveraging the formidable strength of UCSF’s HIV expertise and drawing in other partners to create faculty development opportunities. Their annual training conference brings together leading experts to “train the trainers.” Topics cover up-to-the-moment clinical and basic research findings, drug interactions, cultural and mental health issues, and effective techniques for teaching and mentoring.

Members of the Hawai’i and Chuuk State (Micronesia) AETC at a recent PAETC Pacific Clinicians Conference.

Over its 20 years of operation, the PAETC has developed and honed a five-level program for training HIV care providers. Emphasizing experiential over passive learning, only the first level involves didactic classroom teaching. Higher-level trainings progress through skills-building workshops to training with instructors and mentors in clinical settings, practicums, and mini-residencies, and even clinical consultation by telephone or at the trainee’s clinical site.

Extending Beyond Education and Training

When a clinical site aims to improve or establish a new HIV care program, the PAETC provides not just clinical training, but also technical consultation and capacity building to develop and implement new systems, policies, and procedures. A recent example is the Rapid Testing in Labor and Delivery program funded by the California State Office of AIDS. Its goal is to prevent transmission of AIDS from mother to child by providing rapid HIV testing for women who arrive at hospitals in labor with neither documented prenatal care nor HIV test results. Working with labor and delivery room staff rather than typical HIV care providers adds a new dimension to the PAETC’s work.

Elaborating upon the project, Bernstein says, “We have a three-year grant to make sure that 120 hospitals in California have the policies, the trained staff, the drugs in the pharmacy, and the turnaround in the laboratory to get the results in a timely manner. All the systems and players need to be in place to have this system work. Obviously, it’s not just going and training people that’s going to make the organizational and behavioral changes. It’s finding the right people and getting the decision-makers, all of them, in the same room.”

California’s overburdened state prison medical system is another arena that desperately needs more overarching assistance, to develop and implement new policies and procedures to improve the care of HIV-infected inmates. Reyes explains, “Our goal is to build capacity in the system so that we are not just into one prison at a time.” The PAETC has been working in state prisons—as well as with the California Department of Corrections and Rehabilitation—since 1997.

The effort to help institute high-quality HIV care in the prison setting has proved a long, slow battle in an environment where security is more important than healthcare. Even basic procedures, such as transferring infected prisoners’ medical records when they are moved to new prison, are challenging. Optimism that the PAETC will be better utilized as a resource for the state prison system spiked with the recent inclusion of Jacqueline Tulsky, MD, medical director at the San Francisco branch of the PAETC, on an HIV advisory committee for state prisons.

Leveraging ARI Resources Through Alliances

If the PAETC were a Silicon Valley corporation, it’s likely that a couple of its other key activities would be described as “alliance management” and “business development.” With its offices sitting at the hub of one of the nation’s most impressive collections of AIDS researchers and research programs, Reyes feels very strongly about leveraging the PAETC’s access to expertise within the ARI and beyond. Cross-program collaborations have taken on very different and interesting forms.

One example is a highly integrated training program that addresses the kind of challenges HIV care providers often confront in treating most at-risk populations. As Reyes describes, “We have found great synergies in putting together into packages HIV, tuberculosis, sexually transmitted infection, and addiction treatment information. These are more likely to draw treatment providers into training than if you give just an HIV talk or just a TB talk. They get one-stop shopping.” To create multifaceted training packages, the PAETC typically involves experts from the Curry National Tuberculosis Center at UCSF, the California STD/HIV Prevention Training Center, and the Pacific Southwest Addiction Technology Transfer Center based at UCLA.

Another example of alliance management at the PAETC can be found in its creation of a new Transgender Center of Excellence for HIV Prevention that marks a significant new collaboration between the PAETC and CAPS, two groups that have always enjoyed cross-fertilization. Bernstein describes how the new transgender project will enable research generated for policy to be linked back into the field in the form of training education: “First, we’ll be looking at the research that exists and developing a research agenda for HIV prevention in transgender communities. Years two and three will focus on training around the state, and we will be developing a number of web-based resources.”

As co-director of I-TECH, Reyes has found even broader opportunities for linking the clinical expertise of ARI affiliates, not just with national programs, but also with programs around the world. “I-TECH is collaboration between UCSF and the University of Washington, and our job is to harness the UCSF expertise to work globally.” He frequently links UCSF faculty to I-TECH programs throughout Asia, Africa, and the Caribbean. Carmen Portillo, from UCSF’s School of Nursing, and Betty Dong from the School of Pharmacy have been drafted in as key partners for I-TECH programs.

Reyes has also recruited clinicians from the Curry Tuberculosis Center to provide curriculum review and in-country technical assistance. I-TECH has contracted with Oliver Bacon, MD, from the UCSF Center for HIV Information (CHI) to refine a toolkit that helps clinics set up the kind of mentoring systems that AETC experience has shown to be invaluable.

Exchanging Lessons Between the PAETC and I-TECH

I-TECH was founded five years ago. It is funded by HRSA in collaboration with the U.S. Centers for Disease Control and Prevention with the goal of transferring some of the AETC’s 15 years of accumulated experience from the domestic to the international HIV training arena. Yet, out of respect for the diverse environments in which HIV care is provided around the world, I-TECH’s approach has been to “bring lessons, not models” from the AETC experience. Reyes lists these among the key lessons:

  • Move quickly from classroom to experiential learning in the progression of training.
  • Use multidisciplinary teams for HIV care, especially those that incorporate pharmacists.
  • Recognize the role of a patient’s mental health in their ability to manage their infection.
  • Invest early in establishing a mindset which prioritizes high-quality HIV care when starting new clinics and clinical training.

The learning flow is not unidirectional from the U.S. to global clinics. Just as corporate head offices are now fastidious about circulating best practices from their international affiliates back to their domestic offices, Reyes and Bernstein channel HIV care lessons from I-TECH back to the PAETC. Reyes reports, “They are way ahead of us on integration of rapid testing. They are way ahead of us on innovative models for outreach into rural areas. And they are ahead of us in using text messaging as reminders for adherence and for regular blood donors.”

In the end, it is not operational buzzwords that matter to the PAETC leadership, but delivering high-quality training, education, and technical assistance to the frontlines. And if that requires stretching beyond the “E” and ”T” in their name, using an innovative method or two, and looking throughout the globe for new ideas, you can be sure they won’t hesitate.

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