Youth Environment Study (YES), in collaboration with other local agencies, has fielded more than 40 Community Health Outreach Workers (CHOWs) in San Francisco since June 1986, funded by the National Institute on Drug Abuse. This program, which invented the bleach-and-teach outreach method for AIDS prevention among drug injectors, has been described previously (Feldman et al. 1985; Feldman 1987; Feldman and Biernacki 1988; Newmeyer et al. 1989; Aldrich et al. 1990), and is the model for similar programs in many cities.

Today I am going to outline the 10-day training program we require all CHOWs to take before they hit the streets. We regard this training as essential to their success in preventing the spread of AIDS, and critical to their safety as well. The curriculum was developed primarily by Pat Norman, Director of the YES Training Center, with a lot of input from the founders of YES, Harvey Feldman and Pat Biernacki. We have trained more than 200 CHOWs from California, Hawaii, and other states and nations in these techniques, with funding from the California Office of AIDS.

To be certified by YES and the State of California as a CHOW, each trainee must attend all classes, do all the assignments including a big three-ring binder of readings, and pass a pre/post test, an AIDS test, and a legal issues test with 70 percent or better. Trainees are also evaluated by CHOWs who take them out on the streets.

Day 1. Overview: The YES Outreach Model

Orientation: Pre-Test; YES Outreach Model: Ethnography of Drug Users: Drug Use Patterns

Key to YES's intervention strategy is the development of a meaningful role for CHOWs as caring, non-judgmental providers of health information within the networks of drug injectors they serve (Norman et al. 1989). After an orientation in which trainees describe their local scenes to us, Dr. Feldman begins an overview of the development of our outreach model by saying, "The aim of our program is to stop the spread of a virus that causes deadly, incurable diseases. Given the consequences of failure at this task, all other considerations are secondary."

The YES model is based on ethnography, understanding a social group from the perspective of its members, rather than on the stereotypes of drug users propounded by the media. During the afternoon, I discuss the science of ethnography as it applies to streetwork, and describe the current patterns of drug use in California.

Day 2: The Clients in their Neighborhoods

Drug Policy History: Drug Paraphernalia: Takin' It To The Streets (Supervisors)

A slide talk on the history of U.S. drug policy leads to show-and-tell of the various types of drug paraphernalia CHOWs are likely to encounter when working with clients. CHOW Supervisors relate their observations of clients in their neighborhoods, with emphasis on applied ethnography, which we call "Takin' It To the Streets." We often take them on bus trips to begin observing street scenes.

Day 3: HIV, ARC and AIDS

HIV Testing: AIDS Diagnoses: Psychosocial Issues
John Acevedo, a great teacher, guides the class through HIV testing, ARC, and AIDS, including clinical protocols. This is considerably more advanced than AIDS 101, because our CHOWs are expected to be street experts, and will be deluged with questions. Psychosocial issues include coping with the fear, grief and anger raised by the disease.

Day 4: Women and AIDS

Pediatric: Women & AIDS: Safe Sex: SPIRITs
Day 4 examines sexual transmission among drug users, their sexual partners, and children. Panels on pediatric AIDS and women's issues turn into frank discussions with women who have AIDS. Safe sex resources are demonstrated. Our all-female SPIRITs (Sexual Partners Integrity Resource Intervention Team) describe their outreach work on the streets. Trainees are then taken out with the SPIRITs and other CHOWs to "scope out" their neighborhoods.

Day 5: Youth, Prostitution and Sexuality

AIDS Test: Youth: Runaways, Prostitution: Racism and Homophobia: Gay/Bisexual Issues
After an AIDS test, Day 5 is devoted to the nitty-gritty of outreach to runaway youth, prostitutes, lesbians, gays, bisexuals and heterosexuals. Outreach supervisors from local youth centers, CAL-PEP ( prostitutes' AIDS prevention), Lesbian/Gay Health Services, and other groups sensitize the trainees in these issues.
Over the weekend, trainees are encouraged to relax, go to the movies, or explore San Francisco with the eyes of an ethnographer rather than a tourist.

Day 6: Cultural Sensitivity

Sweet Grass Ritual: Panels on Native American, African American, Asian/Pacific Islander, and Latino Issues: Common Elements of Oppression.
The new week begins with a Native American purification ceremony, followed by cultural sensitivity panels with leaders of the Native American, African American, Asian/ Pacific Islander, and Latino communities in the Bay Area, and a frank discussion of issues of oppression. This training is designed to raise very personal issues which CHOWs have to deal with every day on the streets.

Day 7: Role of the CHOW: Do's and Don't's of Streetwork

A very detailed examination of the role of the CHOW within networks of drug users is led by Dr. Feldman and our most experienced outreach supervisors. This includes gender issues, techniques for gaining entrance to networks, establishing credibility, responding to crises and dangerous situations, phases of outreach strategy, and the do's and don't's of effective streetwork. Trainees then spend several hours on the streets working with our CHOW teams.

Day 8: Legal and Confidentiality Issues

Street Experiences: Homeless and AIDS: Criminal Justice System: Legal Issues: Confidentiality and Privacy Issues.
Trainees discuss their experiences on the street the previous evening. Then two special populations, the homeless and drug users in the criminal justice system, are examined. The afternoon is devoted to AIDS legal issues, including immigrant rights, and the safeguarding of confidentiality necessary for effective outreach work.

Day 9: Home Care, Volunteers and Field Notes

Legal Test: Home Care for HIV Clients: Volunteers, Resources and Referrals; Writing Field Notes: Documenting Work.
After a legal issues test, practical tips are given on home care for HIV clients, safety precautions, recruiting and keeping volunteers, referrals to service agencies, writing good field notes, and documenting outreach work. Trainees then spend several hours on the streets doing outreach under the careful supervision of our CHOWs.

Day 10: Taking Care of Yourself: Certification

Field Notes Review: Taking Care of Yourself; Post-Test; Final Evaluation; Certification.
Last night's field notes are discussed in detail by the trainees, comparing stories and observations. Pat Norman leads them through a series of exercises to help them deal with the stress and strains of this work, reminding them that taking care of themselves is one of the most important parts of the job. Their post-tests are graded while they review and evaluate what they've learned, and they are certified in a rowdy, raucous, and thoroughly dignified ceremony attended by their families and friends.

We have found that this training, which is constantly reexamined and modified to suit the needs of trainees from different areas, is quite successful in building teams of effective outreach workers. We keep in touch with our trainees and invite them back every three months for CHOW Reunions, which are 1-day inservice trainings on special topics suggested by the CHOWs themselves. We are creating a new profession, of highly skilled, streetwise health educators who serve clients in their own neighbor-hoods, rather than demanding that they come into offices or agencies. We think that this is the wave of the future.

Michael Aldrich, Ph.D., is Training Program Coordinator for the Youth Environment Study I AIDS intervention Training Center, 507-B Divisadero St., San Francisco, Calif 94117. (415) 922-6135.

References

Aldrich, M.R.; Payne, S.F.; Little, S.M.; Mandel, J.; and Feldman, H.W., "Classic Epidemiological Mapping of AIDS Among San Francisco Drug Injectors, 1987-1989," Poster presentation Th.C.705 at the VI International Conference on AIDS, San Francisco, June 21, 1990.

Feldman, H.W.; Mandel, J.; Fields, A., "In the Neighbor-hood: A Strategy for Delivering Early Intervention Ser-vices to Young Drug Users in Their Natural Environments," in A.S. Friedman and G.W. Beschner (eds.), Treatment Services for Adolescent Substance Abusers, Washington, D.C.: National Institute on Drug Abuse, 1985, 112-128.

Feldman, H.W., "Outreach Education to Intravenous Drug Users," Presentation to the Presidential Commission on the Human Immunodeficiency Virus Epidemic, Dec. 18, 1987.

Feldman, H.W. and Biernacki, P., "The Ethnography of Needle Sharing Among Intravenous Drug Users and Implications for Public Policies and Intervention Strate-gies," in R.J. Battjes and R.W. Pickens (eds.), Needle Sharing Among Intravenous Drug Abusers:

National and International Perspectives, NIDA Research Monograph 80, Washington, D.C.: National Institute on Drug Abuse, 1988, 28-38.

Newmeyer, J.A.; Feldman, H.W.; Biernacki, P.; and Watters, J.K., "Preventing AIDS Contagion Among Intra-venous Drug Users," Medical Anthropology, v.10, 1989, 167-175.

Norman, P.; Aldrich, M.; Anacabe, C.; Ozawa, D.; and Karp, R., Outreach to Intravenous Drug Users: A Training Manual for Community Health Outreach Workers and Supervisors, San Francisco: Youth Environment Study