Roles and Challenges of Outreach Workers in HIV Clinical and Support Programs Serving Young Racial/Ethnic Minority Men Who Have Sex with Men

Outreach models used by SPNS Young MSM of Color Initiative sites

Only one demonstration site, Wayne State University, had an existing HIV care continuum that served young racial/ethnic minority HIV-positive clients. The other sites had to design and implement new HIV care systems, including outreach, linkage, health, and support services.

Sites selected their outreach models at the beginning of the Initiative, and could add or discontinue additional outreach strategies throughout the multi-year program. Outreach models evolved substantially, with strategies that did not result in the identification of HIV infected individuals discontinued, and strategies found to be successful by one or more sites often adopted by other sites.

By the end of the Initiative, all eight sites (100%) conducted outreach at health and social agencies in their communities, and outreach to the social networks and sexual partners of previously identified individuals. Three-quarters (75%) (n=6) of the sites conducted social, educational, or other community venue-based HIV outreach and education such as at bars, college campuses, gay pride events, and health fairs. One-half (50%) (n=4) of the sites analyzed HIV epidemiologic and ethnographic data to identify geographic areas with relatively high HIV seropositivity rates among young racial/ethnic minority MSM and then focused outreach activities in those areas. Social marketing campaigns were conducted by 37% (n=3) of the sites to raise awareness among young racial/ethnic minority MSM about the importance of HIV testing and treatment. HIV testing events specifically targeting young racial/ethnic minority MSM were conducted by 37% (n=3). About one-third (37%, n=3) participated in local or statewide HIV prevention planning groups to coordinate services and disseminate information about the site's youth-focused HIV medical and support services. About one-third (37%, n=3) conducted Internet outreach in chat rooms and social networking and dating sites. One-quarter (25%) (n=2) of sites conducted in-reach in the health care systems in which the sites operated such as at emergency departments, outpatient clinics, and sexually transmitted disease clinics. One-quarter (25%) (n=2) of sites advertised through Internet websites or in the print media. Outreach and testing with HIV mobile testing vans was conducted by 25% (n=2) of sites. Drop-in centers specifically designed for young racial/ethnic minority MSM were established by 25% (n=2) of sites. Working For Togetherness and The MOCHA Center established drop-in centers to increase self-efficacy to enter culturally appropriate HIV care and engage in healthy social interaction and development. The MOCHA Center implemented a paid youth advisory council made up of the subpopulations of young racial/ethnic MSM in the Rochester, NY area. The council was led by the site's outreach workers, and served to inform the design of the outreach and engagement strategies used. Several other sites also established similar youth advisory councils.

Linkage models used by SPNS YMSM of Color Initiative sites

Following identification of young racial/ethnic minority HIV-positive MSM through outreach, linkage to HIV care activities were undertaken to help engage them rapidly in medical care. All eight sites (100%) assisted newly-identified individuals to schedule their initial medical visits, arranged for transportation to appointments, placed reminder telephone calls to ensure appointments were kept, and conducted case finding for clients that missed appointments. In addition, outreach workers at 62% (n=5) of the sites escorted individuals identified through outreach to their initial medical visits.

Of the 334 patients included in an analysis of linkage outcomes, 72% (n=239) of patients were linked to care within 30 days of diagnosis, 81% (n=270) within 60 days of diagnosis, and 87% (n=291) within 90 days. Most participants (83%) were retained 12 months after newly entering or re-engaging in care.

Outreach and linkage staffing models

The employment settings in which outreach workers conducted their responsibilities varied. In Oakland CA, Chicago IL, the Bronx NY, and Rochester NY, outreach workers were located in AIDS service organizations. In Harris County, outreach workers were employed by a tax district hospital system. In Los Angeles County CA and Chapel Hill NC, outreach workers were employed in hospital outpatient departments. In Detroit MI, outreach workers were employed by a hospital system's community-based HIV services center. Outreach workers conducted their activities within their organizations, as well at numerous community locations.

All eight sites employed paraprofessional workers to conduct outreach and linkage services, with 63% (n=5) of sites employing full time workers and 37% (n=3) employing part-time workers. Job titles included outreach workers, connection to care specialists, peer youth advocates or specialists, service linkage workers, and supportive case managers. Peer workers who were themselves HIV-positive young racial/ethnic minority MSM were commonly employed. Near-peers (young minority MSM who were HIV negative or did not disclose their HIV serostatus) were also employed. Workers tended to be in their late teens to mid-20s, had graduated from high school and had some college education, had 1–2 years of work experience, and were compensated with annualized FTE salaries ranging from $30,077 to $47,918. Variance in salaries was due to educational attainment, prior work experience, and prevailing salaries in the local job market.

One-quarter (25%) (n=2) of sites also employed mobile outreach and testing workers, and 25% employed Disease Investigation Specialists who conducted partner notification services and linked HIV-positive young racial/ethnic minority MSM to health services. One site, Bronx AIDS Services, deployed volunteer community ethnography-organizers who conducted social network mapping of the target population in the Bronx, disseminated information about risks of HIV infection, encouraged individuals to access counseling, testing, and referral services, and directly assisted HIV-positive youth to schedule medical visits.

Outreach workers provided ongoing linkage activities to ensure that their clients were engaged and retained in care. Workers commonly accompanied clients to medical visits, helped them navigate the health care system, coordinated services with case managers, conducted support groups, organized social and educational events, and offered peer support in initiating HIV medications. The extent to which outreach workers were integrated in the health care team varied among the sites, with some workers being fully integrated into multidisciplinary teams and participating in routinely scheduled team meetings. Other workers had limited integration in the health care teams, with workers' responsibilities ending following referral to medical care.

Results of outreach and linkage activities

The Initiative's outreach activities were launched in 2006 following local and GWU IRB approval. Table 1 summarizes the demonstration sites' outreach and identification activities by age and racial/ethnic minority group. Four sites routinely conducted group contacts, with an estimated 11,049 contacts made with young racial/ethnic minority MSM 24 years of age or younger (mean=1381, median=181 contacts). Contacts were made by SPNS staff at the sites' headquarters or at community locations. About one-tenth (14%) of contacts were made with individuals 13–15 years old, 56% with individuals 16–18 years, and 30% with individuals 19–24 years. Most (86%) of group contacts were African American, while 12% were Hispanic and 2% were of mixed or other races.

Outreach was conducted at sites' headquarters or community-based locations, such as HIV testing events, bars, colleges, mobile testing vans, emergency departments, and in neighborhoods where individuals tend to congregate. An estimated 25,376 outreach contacts were made with young racial/ethnic minority MSM 24 years of age or younger (mean=1153, median=589 contacts). An estimated 17% of contacts were 13–15 years of age, 19% were 16–18, and 63% were 19–24. Almost three-quarters (70%) of group contacts were African American, 29% were Hispanic, and 1% were of other races.

A newly identified HIV-positive young racial/ethnic minority MSM was defined as an individual who does not report having a previous HIV-positive test or who reports his test at the SPNS site to be the first HIV-positive test received. Among the 439 individuals who were newly identified, 45% were tested by SPNS staff, 49% by a partnering agency or designated referral source, and 6% by other referral sources that did not have an ongoing relationship with a SPNS site. Partnering agencies for which HIV-positive individuals were newly identified tended to be hospital HIV clinics or community health centers. Among HIV-positive individuals newly identified from SPNS group or outreach contacts, 78% were African American, 18% Hispanic, and 4% were mixed race. In contrast, 91% of individuals identified by partnering agencies or designated referral source were African American, 8% were Hispanic, and 1% were mixed race. HIV-positive individuals newly identified by other referral sources tended to be more diverse, with 56% African American, 33% Hispanic, and 11% mixed race.

Outreach worker turnover and retention

A typical outreach worker was employed by their SPNS site for an average of 14 months, varying from 3 weeks to 3 years. Of the 51 outreach workers employed by the eight demonstration sites, 57% resigned or were terminated. Sites lost an average of 4.1 workers, with attrition ranging from one to nine workers. One site retained their original outreach worker throughout the entire Initiative. About two-thirds (65%) of departures were due to terminations, typically due to misconduct and failure to fulfill position responsibilities. While 10 voluntary departures were reported in GWU turnover forms, interviews with site managers clarified that many “voluntary” departures were actually involuntary, with workers given the option to leave voluntarily or be terminated. It should be noted that some outreach workers left their employment to enroll in college or to seek promotional opportunities or other programs. On average, it took demonstration sites slightly less than 3 months to fill vacated positions. The median cost of replacing one outreach worker across all study sites was $3144.

Program managers reported that turnover among outreach workers sometimes negatively impacted clients who were in the process of transitioning into HIV care. It was common for workers to establish trusting relationships with clients, and then be fired due to performance problems. Given the critical role that outreach workers played in engaging clients initially, the abrupt loss of an outreach worker during the linkage to care phase may contribute to feelings of abandonment among clients, particularly those who may not have stable or supportive family environments.

Challenges and opportunities in employing outreach workers

Interviews with site managers and facilitated discussion groups with outreach workers were conducted by GWU and SPHERE Institute staff to gain insight into the challenges and opportunities experienced in employing outreach workers. Demonstration sites tended to recruit outreach workers who shared common characteristics with the populations that they were employed to seek out and link to HIV medical and support services. The aim of this strategy was to deploy individuals into the community who were highly familiar with venues likely to be frequented by young racial and ethnic minority MSM at high risk for HIV. Venues included physical locations such as colleges, bars, and neighborhood hangouts, as well as Internet social networking, sites commonly used by MSM. Based on their personal experiences, training, and demonstration site outreach protocols, outreach workers helped their clients to become more aware of the need to be aware of one's HIV serostatus, to engage rapidly in medical care if they were HIV positive, or to reengage in care if they had dropped out.

The workers tended to share common racial, ethnic, and youth cultural experiences with the individuals whom they were employed to assist to engage in HIV care. Almost all outreach workers were young, African American or Hispanic self-identified MSM, with limited educational attainment, work experience, and financial resources. Due to their short time working in professional settings, workers sometimes were unfamiliar with the demands of their employers such as required consistent work hours, accountability, and documentation of activities. Some workers were HIV positive, had recently been engaged in care themselves, and sometimes struggled with optimal treatment adherence. Some workers had earlier or current emotional problems, demonstrated impulsivity common among adolescents and young adults, had negative relationships with authority figures, used recreational drugs, or faced unstable living arrangements and personal relationships. Workers were reported to over-identify sometimes with their clients, with whom they shared many common experiences. Workers often conducted group and individual outreach activities in venues in the evening and on the weekends, leaving little time to socialize with their friends and family. Workers reported that it was common for them to work in settings such as bars, community events, and Internet social networking sites that they would normally visit in their off-work hours. They reported that role conflict and confusion were common, with the desire expressed to be able to behave like other young MSM. These experiences were reported by demonstration site staff to result commonly in conflicts over personal and professional boundary setting. Although outreach workers felt that they were valued for their connection to the target population, some workers expressed concerns that their job role prevented them from fully participating in community life (i.e., attending parties, using internet sites to seek intimate partners, and visiting bars). Some outreach workers reported feeling thrust into the position of being a role model for their peers and clients, often without the necessary skills to fulfill this sometimes unwanted role.

Site managers reported that frequently outreach workers had difficulty in defining and negotiating boundaries between their work and social lives appropriately, which were major factors driving outreach worker terminations. Outreach workers were charged with recruiting clients with whom they shared substantially similar backgrounds and experiences. They often interacted with clients and potential clients in social settings such as bars, Internet chat rooms, and student centers. According to site staff, these informal settings encouraged outreach workers to adopt an informal attitude toward their work, which suffered as a consequence. Site staff reported that terminations were often due to exercising poor judgment in mixing work and personal space, failure to adhere to program or agency policies and procedures, and misconduct. Such misconduct manifested itself in behaviors such as using project Internet sites during work hours to communicate with friends. Blurred boundaries were sometimes accompanied by compromised confidentiality. One site's outreach staff noted that when peers tried to recruit from within their social networks, they placed themselves and their friends at risk of involuntarily revealing their HIV status.

Many of these issues were due to the underlying tension of the nature of the outreach worker position. The relative youth of outreach workers made them skilled in working with other youth, but made them especially susceptible to misconduct resulting from lack of boundaries, as well as intense job pressures. Furthermore, young outreach workers may experience depression and substance abuse, both of which impair work performance. Finally, many site managers stated that the problems associated with young outreach workers are compounded by the ill-defined responsibilities of their positions. While outreach workers' duties required independence, the young age of the workers may have necessitated more structured supervision than occurred at some sites. Outreach workers were charged with a wide range of tasks, going well beyond street outreach, and their responsibilities often changed over time. Because the job in its final form may have departed from the job as it was originally described, it was difficult for outreach workers to assess both their own readiness for the work and the cost to their personal lives.

GWU sponsored outreach worker meetings in 2006 and 2007 to share common challenges and identify ways to overcome them, gain skills, and create an outreach worker support system. Reports were prepared summarizing the meeting discussions. Table 2 summarizes the tension experienced by outreach workers in balancing their employers', clients', and their own expectations.

Staff from sites located in rural and smaller urban localities described the unique retention and hiring challenges that programs face when located in these environments. Such regions often lack an established visible gay, lesbian, bisexual, and transgender (GLBT) community (and even less visible GLBT communities of color), and safe spaces for MSM to socialize. The interviews suggested that the absence of such settings could result in higher turnover because the confidential nature of outreach work often prevents workers from connecting with their peers socially and drawing essential emotional support from them. The demonstration sites limited how outreach workers could behave in their communities and when MSM communities are already small, an outreach worker's position can dramatically undermine their social life, particularly when socializing in gay bars and clubs and use of Internet dating and sex sites is restricted.

Program managers reported that it was important to develop and sustain protocols for outreach activities that offered clearly defined expectations and performance standards. Firm and consistent supervision was identified as providing a professional foundation for outreach workers who may not have had prior experience working in a structured environment in which they were accountable for their time and their activities.

Site managers commonly reported that salary was an important factor in encouraging retention among outreach workers. Workers themselves expressed dissatisfaction that they were the lowest paid team member, and often were asked to conduct outreach services in venues and neighborhoods where personal safety was not always assured. Several workers commented that other team members would not accept the work environment in which outreach activities had to be undertaken.

Conversely, managers stated that the combination of good salaries, high-quality benefits, and set hours increased outreach workers' investment in their jobs. Since full-time employment allowed sites to incorporate outreach workers as team members, managers of many sites stressed that the structure of the position was a factor in outreach workers' success. Full-time outreach workers were offered more opportunities for cross training within the care team. Integration into the team most likely resulted in outreach workers feeling more invested in the demonstration site's activities. Full-time employment was also an important factor for HIV-positive outreach workers, as health insurance was available.

Recommended strategies to improve retention of outreach workers

Demonstration site managers and outreach workers offered suggestions for minimizing turnover among outreach workers in other HIV care systems. HIV program managers need to be explicit about outreach workers' responsibilities and their employers' expectations. Grantees noted that outreach workers had difficulty adjusting to the extensive scope and ill-defined responsibilities of the position. Many staff felt that it was important to create a rigorous interview process emphasizing the importance of job responsibilities and boundaries, and requiring candidates to meet the entire project team. Sometimes interviews involved role-plays to highlight these issues. For example, at one site, staff asked candidates to react to scenarios such as the following: “Imagine you are counseling a person who has been having unprotected sex. What would you say?” Interviews at some demonstration sites included a member of the target population on the interview committee. After being disappointed with the high degree of turnover at other SPNS sites, the project coordinator at one site became more frank about the challenges of the position during interviews with new candidates. Interestingly, while several grantees expressed frustration with the highly bureaucratic and time-consuming recruitment processes imposed by their employers, this laborious process acted as a filter to ensure that applicants were serious about the position.

It was suggested that outreach programs might consider hiring individuals familiar with the organization. Several sites hired applicants already familiar with their programs to help ensure that potential candidates would be more likely to understand the challenges of the outreach worker position. For example, in Los Angeles County, as soon as they experienced a departure, they hired a replacement outreach worker from within the county agency. Similarly, several programs hired volunteer staff or former program participants. For Bronx AIDS Services, hiring participants as “volunteer-stipend hybrids” proved very effective. By contrast, AIDS Project of the East Bay reported negative experiences hiring former program volunteers, who generally proved to be ill prepared for formal, structured employment.

Many site managers and outreach workers reported that it was important to integrate outreach workers into the multidisciplinary team by offering competitive salaries and benefits, recognizing their input in the project's development, and providing opportunities for cross training. For example, Wayne State University encouraged outreach workers to shadow other project staff and attend relevant conferences. University of North Carolina staff noted that cross training could compensate for the social sacrifices their outreach worker had to make by providing them with valuable skills that would prepare them for future employment opportunities

Challenges inherent to outreach can be addressed effectively through training. Demonstration sites provided many different types of training, depending on their agencies' requirements and available resources. For example, several sites sent outreach workers to free, formal training that staff had to pass before starting their responsibilities.

While demonstration site staff did not express strong feelings about whether training should be formal or informal, they did state that the curriculum should be designed to help outreach workers confront and effectively address challenges in the workplace. For example, to assist their staff to separate their work and personal lives, Wayne State University managers carefully reviewed agency protocols for cell phone usage, dress code, and Internet behavior. Several site staff suggested that training include discussion of professionalism, as well as guidance and feedback on how to represent the organization appropriately (e.g., when presenting to potential collaborating agencies).

Managers and outreach workers stated that mentorship that goes beyond traditional supervision is needed. Demonstration site staff uniformly agreed that working with outreach workers required added supervision and mentorship, particularly for the younger staff who more closely mirror the target population. Staff of several programs with high turnover observed that the demands of the outreach position often exceeded the capacity of young workers to handle them, potentially setting up workers for failure. Several sites implemented mentorship programs to help outreach workers define and meet their personal and professional goals. In several cases, this took the form of periodic one-on-one meetings. For example, supervisors at one program worked with outreach workers to articulate a set of goals that the individuals wanted to achieve while in their position, such as to stop smoking marijuana or to complete their high school education. The University of North Carolina implemented an informal mentorship system. Managers discussed a range of issues with outreach workers, including how to establish and maintain appropriate boundaries with clients. Several managers recommended that future outreach programs incorporate training in youth development, in order to equip program staff to supervise outreach workers.

Managers and outreach workers reported that it was important to obtain feedback from workers about their concerns and recommendations for refining their job responsibilities. It was stressed that discussions between managers and outreach workers be open, and workers be helped to feel comfortable expressing their concerns and opinions. Wayne State University managers recommended that programs periodically debrief their outreach workers, so that they can productively express the concerns they have and the challenges they face in the workplace. Similarly, convening annual meetings of all SPNS outreach workers provided a safe, confidential setting in which outreach workers shared their concerns and identified areas in which they felt that managers and medical personnel could better integrate outreach workers in the team. The results of these meetings were shared with demonstration site staff, who integrated the workers' suggestions to improve working conditions and better integrate the workers in the teams.