Not Another HIV Group!

We tend to forget that school was not a pleasant experience for most of our clients. As children, they often found it difficult to identify, whether culturally or ethnically, with their teachers and other school leaders. From what my clients have shared with me, there was a disconnect between what they were learning in school and what they were experiencing in the outside world, their neighborhoods and at home.

The majority of my clients have spent over half of their lives in jail, running the streets and living life on an endless high -- unattached to anyone, including themselves. Many have stated that most of what they do know, reading or math skills, they learned in jail. Sitting in a classroom setting is difficult -- they do not want to be preached to. They want their learning to be relevant for their continued survival -- and they want to be in full control of how they are going to survive living with HIV/AIDS.

How, then, does a medical clinician attempt to address the need of client-based HIV education in an urban community clinic or day treatment setting that provides medical and mental health services to the triple diagnosed?

An effective facilitator needs to understand his or her audience and accept where each listener may be in their intellectual development. The facilitator must then foster a safe environment in which clients can openly express their lack of basic reading and writing skills. The facilitator must know when too much information is being offered and not enough is being absorbed. In this setting, how does a group facilitator achieve mastery in teaching basic biological processes using language that will not intimidate, but empower? For me, attaining this skill has been about realizing that my own school experiences were not very different from those of the clients. When the facilitator finds that commonality between herself and her audience, communication takes on a level of authenticity that can reach that audience.

There are some techniques that I have used to engage clients who may be easily turned off by the idea of listening to a lecture. My groups are arranged in a semi-circle to give everyone equal advantage in listening to and engaging the speaker. It also allows for eye-to-eye communication when clients are actively sharing their views. I enjoy writing on a blackboard and using visual diagrams to illustrate a point. Clients enjoy seeing concepts written down or in diagram form.

Another technique is to incorporate an interdisciplinary approach. I solicited the assistance of the Creative Arts Therapist to create a play about how HIV attacks CD4 cells and how these cells lose their ability to modulate an immune response. The clients were amazed that roles could be attributed to biological processes. Many were able to explain the whole process of how HIV attaches to vulnerable immune cells and how it reproduces itself throughout the host's system.

Simple experiments, such as having clients measure their vital signs and relate these to physiological and disease processes, make the learning experience more meaningful. In addition, there is a sense of pride, a sense of greater understanding of how their bodies work. When they visit their primary care providers, they may feel more empowered to ask questions that will help them achieve greater adherence to their HIV medications.

The following are recommendations for effective client-based HIV/AIDS education:

• Discussions cannot be solely clinically based -- "life issues" must be incorporated into a medical group. Clients with a history of substance use, homelessness and other psychosocial issues need to understand how and why they were susceptible to the virus in the first place.

• Clients enjoy taking on an active role in designing groups. Curriculums are not effective because they are too predictable, and clients can feel frustrated about not having the opportunity to discuss issues that they feel are relevant to them.

• Facilitators must find the balance between allowing clients to express their views and moving the discussion in such a way as to relate their views and experiences to HIV and treatment adherence.

• Sharing statistics is an engaging segue into discussing HIV complications. Statistics that show survival rates for individuals with a certain HIV viral load and/or CD4 count, on or off treatment, have been very successful in helping clients begin to consider HAART who have been reluctant to start medications previously.

• Some clients feel that it is not worth their effort to achieve an undetectable viral load because they have not planned what they are going to do with the rest of their lives. Some have admitted not wanting to take medications because they will no longer have a reason to take illicit drugs. An effective community-based client education program will have to provide supportive services to deal with these kinds of issues and address these concerns in an appropriate setting.

Even topics that may not seem relevant to HIV -- such as The Implications of the Tuskegee Experiment -- are quite appropriate in this setting. The medical clinician who takes on the role of transmitting vital medical information to an audience who may feel disempowered to change the course of their destiny needs to bring all their experiences, talents, medical knowledge, and compassion to the table and see what unfolds.

Clara LaBoy is a physician assistant and former Executive Director of Housing Works' East New York Adult Day Health Care Center, Brooklyn, New York.