The instruments in this Treatment Improvement Protocol (TIP) were designed for use by workers in the fields of both alcohol and other drug (AOD) abuse and infectious diseases. This TIP represents one of the first attempts to provide a multidisciplinary approach to these public health problems.
This chapter focuses on the rationale for screening for both of these problems, the purposes and limitations of the instruments, training of staff in conducting screening interviews, and considerations in implementing a screening program for AOD abuse and infectious diseases. The discussions presented here are intended in part to help program staff achieve a basic understanding of, and level of competency in using, the screening instruments presented in this TIP. This chapter can be used as a primary tool for training staff in using the instruments. Trainers should also be familiar with the content of this document.
One of the basic tenets of understanding the process of screening is the recognition that its goal is not to diagnose a specific problem, but to determine whether an individual needs further, more comprehensive, assessment and evaluation. Several aspects of the screening process should therefore be clarified to personnel who will be administering the screening instruments for AOD abuse and infectious diseases.
Although the screening process is often used to identify individuals at high risk for a diagnosis, it is never diagnostic in and of itself.
An individual with a positive screening test must have a clinical assessment before a diagnosis can be made and before clinical management can begin.
Screening instruments are often intentionally designed to achieve high sensitivity - to identify large numbers of persons with the disease or condition. Therefore, screening tests may have low positive predictive value; in other words, many individuals with a positive screening test will subsequently be found not to have the disorder. Conversely, a negative screening test may not necessarily rule out the possibility that the disorder is present. (See Chapter 1.)
To understand the rationale behind screening for AOD abuse and infectious diseases, workers administering the instruments need to appreciate the magnitude of these problems in the populations with which they come into contact. As discussed in Chapter 1, both AOD abuse and infectious diseases, such as tuberculosis (TB) and sexually transmitted diseases (STDs), are enormous public health problems. Although each of these problems alone has broad public health implications and incurs significant costs, the impact of both together on the acquisition and transmission of human immunodeficiency virus (HIV) has increased their individual importance even further.
Furthermore, the two problems overlap. TB and STDs, for example, are highly prevalent in populations in which AOD abuse is common. It has been estimated that as many as 30 percent of patients admitted to general hospitals have some type of AOD abuse problem (Moore et al., 1989). AOD abuse is associated with behaviors (such as high-risk sexual behavior and needle-sharing practices) that increase the risk for contracting STDs and HIV. It is also linked to social situations (such as those in homeless shelters and jails) where crowding increases the risk for acquiring communicable diseases.
Treatment exists for both AOD abuse and infectious diseases. With the exception of viral diseases such as HIV and herpes infections, which can be treated but not cured, infectious diseases can be treated effectively. Substance abuse treatment, using a variety of modalities, can also be effective, although it requires a more comprehensive and long-term approach. Screening can play an important role in containing these two problems if it is employed as a first step toward assessment and treatment.
The question arises, however, about the usefulness of screening instruments if they identify clients who need services that are not available because of an already overtaxed treatment system. It is hoped that the use of these instruments will, at the least, serve a valuable information-gathering function that will indicate needs and eventually lead to more funding for treatment resources.
Despite the important reasons to screen for alcohol and other drug problems and infectious diseases, potential barriers also exist that may make service providers apprehensive about implementing the screening process:
In the absence of an understanding of how the two problems are linked, screening for infectious diseases by AOD workers, and vice versa, may seem irrelevant to the service provider's and agency's goals.
Service providers may not trust the accuracy of the self-report method (see the section in Chapter 1 on "Limitations of Self-Reporting").
Existing workloads may overwhelm service providers, who may believe that screening for both AOD abuse and infectious diseases will make their jobs more complicated and difficult.
If treatment for AOD abuse or infectious diseases is not available, or if clients do not comply with treatment, service providers may feel discouraged about identifying problems for which treatment is unavailable or believed to be ineffective.
Service providers who have inadequate knowledge of treatment and referral sources for AOD abuse and infectious diseases may believe that screening for these problems is not worthwhile.
Education about the relationship between AOD abuse and infectious diseases is key to overcoming such misconceptions and apprehensions on the part of staff. Workers using these instruments need to understand AOD abuse and infectious diseases as two interrelated problems that must be approached together for interventions to be effective.
It may also help to focus on the benefits that screening can have for patients. Both infectious-disease and AOD agencies have patient care as their primary mission. These instruments can identify problems that affect patients' health and that may also have a direct impact on their ability to complete courses of treatment.
As with any screening process that takes the form of an interview, administration of the instruments presented here requires specialized skills on the part of the interviewer in order to establish a rapport with the client. These skills include using good listening techniques and the ability to communicate empathy, support, and understanding and foster an atmosphere of mutual trust and respect.
To employ these skills effectively, workers may need training in order to allow them to be more comfortable with the screening instruments. This may be especially true because of the highly personal and intimate nature of many of the questions, such as those dealing with sexual behavior. Achieving an atmosphere of mutual respect and honesty under the constraints of limited time and privacy poses a significant challenge, requiring the interviewer to be flexible and creative. Training in techniques that can be used to meet this challenge can be helpful in this regard. Exhibit 4-1 shows a suggested curriculum of topics and techniques that should be covered in basic training to administer the screening instruments.
Many types of workers can be expected to need or want training in administering the instruments. Chapter 1 ("Intended Users, Audiences, and Settings") gives numerous specific examples of the types of workers to be trained, along with the populations and settings in which screening can be performed. Regardless of the types of professionals being trained, trainers should be familiar with all the populations in which screening will be undertaken.
Although many workers providing services for AOD abuse already possess the skills necessary to administer screening instruments, it is anticipated that specialized training will be needed for staff using the instruments presented in this document. A primary reason for the need for specialized training is that the instruments are designed for use by staff who will be working in unfamiliar content areas. AOD workers, for example, may have scant knowledge of the issues surrounding infectious diseases in the individuals with whom they work. Conversely, infectious-disease workers may have little understanding of AOD abuse and dependence.
Moreover, many of the topics addressed in the instruments, such as sexual habits and history, are highly sensitive and personal in nature. AOD and infectious-disease workers may not be comfortable talking with clients about these intimate areas and may need specialized sensitivity training.
Specialized training is also needed because the clients to be screened can be difficult to work with or may be perceived as noncompliant by the workers administering the instruments. Screeners need to develop skills for working with difficult clients. They must be aware of the possibility that clients may deny or minimize problems, give inconsistent answers, or be temporally impaired, all of which can bias the responses. In addition, the settings in which many clients will be found may not be conducive to talking or interviewing. Screeners must learn how to function effectively under suboptimal conditions.
Incorporated in a training program for using the screening instruments should be a review of interpersonal skills, including some basic communication and interviewing techniques, and guidelines on how to deal with a range of client reactions. Screeners should be able to administer the instruments in a manner that is casual, friendly, nonthreatening, and nonjudgmental in terms of both verbal and body language.
Screeners should also be familiar and comfortable with local vernacular in describing terms for illness or behavior, as well as with regional and cultural differences in the population being screened. Such differences may relate to terminology or practices that may be prevalent in certain geographical areas. To enhance the usefulness and effectiveness of the instruments, efforts should be made to educate the target population about the rationale for and uses of the instruments in language they can understand.
At the completion of the training, users of the screening instrument should be:
Able to explain to clients the reasons for screening
Familiar with the rationale for questions contained in the instruments
Comfortable in administering the instruments
Able to interpret the results
Familiar with the appropriate referral actions that should be taken after identifying a person in need of further assessment.
Training programs should involve the staff of both AOD and infectious-disease agencies, and individuals conducting the training should be selected from a variety of related disciplines. Training programs should be conducted in both AOD and infectious-disease work settings to help workers become familiar with other agencies. AOD and infectious-disease staffs should be supervised by personnel from both disciplines to ensure that referral linkages are operating effectively.
Cross-training of AOD workers by infectious-disease personnel and vice versa will enhance workers' understanding of the issues confronted in unfamiliar disciplines. Allied health professionals, such as physician assistants, AOD abuse counselors, and other paraprofessionals, should also be involved in the training program. The individuals selected should possess characteristics and skills such as acceptance by the target population, credibility, effective communication skills, and an understanding of and ability to maintain confidentiality.
Supervisors and program managers should also be an integral part of the training process, even if they will not actually be administering the screening instruments. The following are some topics that might be covered for supervisors and managers receiving training:
Funding and other resources
Staffing patterns (e.g., integrating screening tasks into existing job descriptions)
Importance of supporting workers
Providing opportunities for feedback from staff who are administering the screening instruments
Allowing release time for employees to receive training
Providing periodic inservice training
Ensuring that services exist for clients who score positive on the screening instruments
Developing memoranda of understanding with referral agencies
Helping other agencies with mutual problem solving.
Training should focus on those areas about which workers have limited knowledge and with which they need more familiarity, particularly the problems and issues confronted in other disciplines. For example, infectious-disease workers may have little awareness or knowledge of the problems faced and the approaches used by AOD workers. Similarly, AOD workers may have little knowledge of the clinical syndromes of infectious diseases or of the public health approaches traditionally used to combat them. Many AOD workers may also feel uncomfortable asking the detailed sexual questions that are integral to the infectious-disease screening instrument and must be asked in a nonjudgmental manner. Similarly, many infectious-disease workers may feel uncomfortable talking about substance abuse with clients.
Some workers may harbor personal and professional biases against the individuals screened. These biases, which may be unconscious, need to be confronted in those receiving training. Biases may be based on cultural and ethnic background or sexual orientation, or may take the form of discrimination against those who abuse AODs or are infected with HIV. Experiential group process activities such as role-playing and focus group strategies, efforts to explore and address expressed concerns, and consciousness-raising can be effective in addressing biases and in promoting more equitable treatment of clients encountered in outreach settings.
Training should also emphasize the responsibility of the screener to explain the consequences of screening and referral to clients. Screeners should develop the necessary skills to anticipate a range of emotional reactions from the client in response to the screening instrument and to reduce clients' anxiety about the screening process. Training must also prepare screeners to face noncompliant clients, in whom denial and resentment may represent a challenge. Clients need to understand that screening is not diagnosis, but a way to assess risk factors, to trigger referral, and to prevent the onset and transmission of disease.
Those who work with people with AOD problems may be particularly frustrated by clients' periods of remission interrupted by relapse, a typical pattern in individuals with these disorders. Workers who are unfamiliar with AOD abuse disorders need to be educated about the cycle of remission and relapse that is often seen in people with these problems. Understanding that this cycle is often a part of the normal recovery process will help staff work more effectively with these clients.
Staff members who will be screening clients need a basic understanding of the instruments' limitations and purpose. They should understand the distinction between screening and assessment; that the purpose of screening is not to diagnose or treat AOD abuse or infectious diseases, but to identify individuals who are at risk for these problems and who will warrant a more indepth clinical assessment; and that a negative screening result does not necessarily either indicate or rule out the presence of these problems.
Staff should be educated about the legal issues concerning clients' confidentiality and their relation to recordkeeping and public health requirements to report communicable diseases. Screeners should be educated about what kind of client information should be kept and how it should be transferred. These topics are covered in greater detail in Chapter 5 and should be reviewed carefully.
Appendix B presents information about training outreach workers in screening populations for infectious diseases.
Before administering the instrument, interviewers should talk with the client about the purposes of screening and how the results will be used. Clients may be more willing to be forthcoming in their answers if they understand these points before the screening begins.
The screening instruments should be administered in a setting that is as comfortable as possible. Interviewers should be trained to ask questions straightforwardly, without either verbal or nonverbal signs that may discourage the client from giving an honest answer. Since the questions have only discrete answers of either yes or no, the interviewer must employ the basic counseling skills of probing, listening, and empathy.
Under ideal circumstances, the interviewer should not rush from one question to the next, but should pause between questions, allowing time for discussion when it seems appropriate. In general, it is desirable to adhere to the wording of the questions in the instruments. It is expected, however, that some
flexibility in the wording of the questions will be needed.
Sometimes, the interviewer may want to repeat the person's responses, particularly if the client appears to be denying that he or she has any problems. For example, consider question 7 in the AOD abuse screening instrument: "Has your drinking or other drug use caused problems at school or at work?" If a subject answers "no" to this question, the interviewer may want to follow with "So you would say that your drinking or other drug use has never led to problems at school or at work. Is that correct?"
Workers and trainers who are culturally competent - who understand the language, culture, and ethnicity of the populations being served - are crucial to the effectiveness of the screening process. Developing cultural competence should be an integral part of the training process, and policies and procedures that promote the recruitment and retention of culturally competent personnel should be developed. Appendix C contains two articles, "Cultural Sensitivity: Treatment for Diversity" and "Self-Instruction to Prevent HIV Infection Among African-American and Hispanic-American Adolescents," that provide insight into some cultural considerations.
The initial and ongoing training of all staff should be designed and implemented to address differences in cultural and ethnic backgrounds, language, gender, sexual orientation, and economic status among the communities being served. It may be helpful to draw trainers from the target populations, such as recovering AOD abusers and HIV-positive individuals.
Workers will also need training in the scoring and interpretation of screening results and appropriate referral actions. Training in these areas can focus on tracking clients for whom a referral was made to ensure that he or she received appropriate followup services.
It is also essential to address safety issues in training. For example, instruction should be provided concerning how to react to a client who is out of control and how to de-escalate a dangerous or potentially dangerous situation. Basic safety guidelines for interviewers include the following:
Do not attempt to force someone to respond if they refuse to answer questions.
Leave if a situation does not feel safe.
Back up other workers when possible.
Be alert, particularly when doing street outreach. Physical safety is an issue not only in direct contact with clients, but also because violence may be more likely in some neighborhoods.
Health-related safety issues include possible exposure to TB through airborne transmission and to HIV through needle sticks. Occupational exposure to HIV and even TB, however, can be prevented by following universal precautions for infection control (CDC, 1987; 1990).
Depending on needs and resources, training programs for administering the screening instruments may range from a few hours of instruction and orientation to a full-day session. At a minimum, however, this TIP should be read and reviewed by staff members who intend to use the instruments.
Joint training by workers from a variety of service agencies will help provide a multidimensional understanding of the screening and referral processes, which will improve assessment and treatment.
Whenever possible, training sessions should include personnel from all of the agencies that will be involved in administering the screening instrument.
Training should be supplemented with appropriate visual aids, such as videos, slide presentations, and printed materials. Videos or slides, for example, can be helpful in explaining infectious-disease processes to AOD workers and can help standardize training. State AOD agencies and health departments associated with the screening process should take responsibility for keeping a current list of available resources for assessment and treatment.
Other training techniques include field demonstrations, in which staff can be asked to administer the instruments to actual clients in a "trial run" and the process and results critiqued to identify potential problem areas. Role-playing is especially useful in exploring some of the sensitive areas in the questionnaires, as well as in piloting the instrument itself.
Drawing on existing expertise outside the agency (for example, an AOD community-based organization bringing in infectious-disease workers) can be accomplished in cost-effective ways through brown-bag lunch sessions or an exchange of personnel for training purposes. Unstructured round table discussions are another useful way to explore ideas related to this material. These techniques do not necessarily require additional staff.
Training updates should include revisions of the content of the training curricula and findings related to the screening results. At the agency level, group debriefing sessions can help workers let off steam, address problems, and keep the process on track.
In implementing a screening program for AOD abuse and infectious diseases, workers and managers should set program objectives with an eye toward what is practically attainable. In an ideal system, referral is smooth, treatment is available on demand, feedback is steady and regular, and information from all involved agencies is processed in a centralized computing system and coordinated by a case manager with an interdisciplinary perspective. Ideally, a comprehensive, computerized directory of services that includes the full scope of intervention modalities is maintained and continually updated. Although these ideals are not always attainable, they should be integrated as much as possible into existing settings, and strategies to use the strengths of local programs and resources should be developed.
Implementation of a screening program for AOD abuse and infectious diseases requires collaboration among the agencies and organizations that will be involved in screening efforts. To facilitate this collaboration, the Federal Government can guide the States in providing assistance for local jurisdictions when necessary. At the highest State levels, collaboration is necessary between State AOD agencies and health departments. Such collaboration between experts in AOD abuse and infectious diseases is required for the screening instruments to be widely and successfully used.
In addition, referral and treatment networks that cross traditional agency lines need to be established. An interdisciplinary program will give States the opportunity to lead the way in dealing creatively with the health crises incurred by AOD abuse and infectious diseases.
In light of other State health care responsibilities, it is clear that at least minimal additional resources will be needed to implement the recommendations presented here. Additional Federal resources will also be needed if these recommendations are successful, as they will create new demands for services on a statewide level.
Outreach is an essential component of screening for AOD abuse and infectious diseases and is an important part of any public health effort that addresses these problems. Outreach efforts to screen for these problems should consist not only of connecting with clients on the street who may not be reachable through established systems, but also of proactive attempts within systems and institutions to reach anyone at risk for AOD abuse or infectious diseases.
Equally important is the need to create an environment in which the value of the screening instruments is recognized. There is also a need for collaborative efforts among agencies for the instruments to be used effectively and to be incorporated into existing systems as efficiently as possible.
States can help create the climate for cooperation by sponsoring training sessions bringing together personnel from the various disciplines and departments that need to be familiarized with the screening instruments. These personnel include not only public health workers, clinicians, and outreach workers, but also supervisory personnel, who will supervise outreach staff and must endorse this process if it is to be successful. Community leaders, who can also provide valuable input and support for the effort, also need to be involved.
Finally, on a systemwide level, the screening process should be monitored and evaluated at the agency level to ensure that appropriate numbers of individuals with AOD abuse problems or infectious diseases are identified and successfully referred for appropriate assessment and treatment.
Liability is a legal issue that varies from State to State, or even community to community. It is the responsibility of agency directors and screeners to be aware of the current laws and regulations that apply to them. Of particular importance is the need for administrators of the screening instruments to be knowledgeable about the consent process, including how to prepare and present a consent form. (These issues and the current laws and regulations are discussed in greater detail in Chapter 5.)
In addition to these legal issues, use of the screening instruments can also pose a number of ethical questions, and training should approach these areas openly. In screening for AOD abuse and infectious diseases, the interests of the screening agency, of the client, and of the community may conflict, and seldom is there a "right" answer.
For example, an inherent conflict exists between public health concerns and client autonomy and self-determination when HIV-infected or infectious TB patients fail to take measures to reduce the risk of transmitting their infection to others. Screeners have a responsibility to inform clients with infectious diseases about the implications and potential consequences of having unprotected sex or sharing needles.
Such a discussion, however, may raise clients' concerns that someone will notify their partners about medical risks. This could prevent clients from seeking needed services. Screeners must therefore be clear, both in their own minds and in conversations with clients, about clients' rights to confidentiality and privacy and when these rights may be infringed upon for public health reasons. The use of role-playing can be a helpful training technique to address this issue with program staff.
Another ethical problem may arise if screening identifies problems for which referral and treatment services do not exist. Ideally, the data created by the screening instruments should prompt funding to provide the necessary resources (similar to a needs assessment). Lack of resources emphasizes the need for establishing priorities for treatment and accessibility for competent care. Highlighting gaps in services may encourage programs to determine whether internal changes can promote more efficiency and an enhanced ability to serve more clients.
Each agency involved in administering the screening instruments must form its own policies concerning complying with Federal and State confidentiality laws and regulations (see Chapter 5), the recording of results, addressing requirements for interagency reporting, and communicating screening results to clients. Orderly recordkeeping facilitates the documentation of successful client referrals, the implementation of appropriate interventions, and the use of data for epidemiological surveillance purposes.
Because of confidentiality requirements, whenever possible, records should be kept in such a way that the client is not directly identified with or connected specifically to a screening result. Clients may need reassurance that information, especially about sensitive issues such as sexual practices and illegal drug use, will remain confidential. If clients believe their confidentiality will be breached, they will not participate in the program. (See Chapter 5 for a full discussion of recordkeeping in relation to legal requirements to maintain confidentiality.)
When indicated by the screening results, referral should be made for further assessment. The importance of appropriate referral cannot be overemphasized, but the opportunity for appropriate referral will vary according to local resources.
Effective referral requires more than simply providing the client with a written note. Ideally, a block of time should be set aside to discuss referral options with the client and to answer any questions he or she may have. For some clients, an assessment of sobriety should be done to determine whether he or she understands the referral recommendation.
Ideally, clients should have some input into the referral process. If several equally appropriate options exist, clients may be asked which program they would prefer. This encourages clients to become active participants in the process and to make their own decisions. When possible and appropriate, the screener making the referral should schedule the assessment appointment for the client. The screener should then follow through to ensure that the client gets to the site, or should accompany the client to the referral site. If possible, tokens for cab, bus, or other transportation should be provided. Child care may also be needed.
Incentives can be built into the referral process to encourage client compliance. Incentives may include free medication, priority admission, coupons for treatment, or free transportation (tokens or cab service). It is essential, of course, to ensure that such incentives are actually available before making promises to the client.
Both the agency making the referral and the service provider accepting the referral should be familiar with the screening instrument. This can be facilitated by sending the completed screening questionnaire to the referral program, with the client's consent.
Because of the dynamic nature of the health care system, program managers should periodically review the clinical services needed by the program's clientele and should identify appropriate providers of those services. A mechanism should be established to ensure that these providers are notified in advance of individuals being referred to reduce the chances of clients "slipping through the cracks," and the referring agency can be notified if a client does not appear for a scheduled appointment.
The agency undertaking the screening should identify needs in order to facilitate the referral process. For example, increased availability of appointments or more funds for testing and personnel may be required. Clients' transportation needs also must be met for a referral program to be successful. Wherever possible, collaborations with receiving agencies should be created to maximize the options available to clients and to facilitate their ability to keep appointments.
Clients who receive a positive score on a screening instrument should be referred for further assessment, and case management should be an integral part of this process. Early involvement of case managers or social workers can facilitate the referral process. More targeted case management can occur later in treatment for either medical management of disease or supportive social services.
How case management is implemented and integrated into the referral process varies among different organizations and agencies that provide human services. Each agency will need to adapt its own model of case management to fit its functions and goals, but, in general, the services overseen by case management consist of the following components:
Working with the community to promote understanding and acceptance of AOD and infectious-disease problems at the grass-roots level is an important step toward ensuring the success of a screening program. To involve the community, individuals and organizations with an interest in these problems need to be identified. Examples include opinion leaders with proven track records, grass-roots organizations, public health care providers, politicians, nonprofit community-based organizations, schools, and churches. The list may encompass groups as diverse as AIDS service organizations, the Girl Scouts, and the Junior League.
Experts in the fields of AOD abuse and infectious diseases should set up informational sessions on the need for AOD and infectious-disease screening in the community. These sessions need not be dedicated solely to the topics of AOD abuse and infectious diseases but can incorporate other agendas in order to attract a broad range of community representatives. Local television shows and newspapers aimed at specific ethnic groups, especially in larger communities, are also useful ways of disseminating information and promoting understanding of the need for screening.
People who have received services for AOD abuse and/or infectious diseases can also be recruited as volunteers to educate and involve the community. Client testimonies and personal stories are an effective way to capture the interest and commitment of members of the community. Celebrities and athletes are also sometimes interested in publicizing these issues. Organizations providing education, support, and advocacy for gays and lesbians have been very successful in using this avenue of public education about HIV and AIDS.
It is also necessary to anticipate what new programs and future settings will be useful for identifying clients and conducting screening. For example, there will be a great emphasis in the near future on directly observed therapy (DOT) for TB. This is a management strategy designed to address the problem of low medication compliance rates in TB patients, which is an important factor in the spread of multiple-drug-resistant strains of TB. With DOT, short courses of therapy are administered by having patients come into the clinic two to three times a week to receive their medication, or by having field workers administer medication to patients (American Thoracic Society, 1992). Other new service programs and new settings will certainly offer opportunities for screening target populations for AOD abuse and infectious diseases. Communities that conduct ongoing needs assessments will be better prepared to provide a wide array of services to meet future demands.
Ideally, the model AOD program that is focused on public health features the collaboration of a number of agencies and includes interdisciplinary joint training and evaluations. A program that utilizes the screening instruments presented in this TIP optimally would be governed by a strategic planning process that targets the epidemics in the community, taking a broad, public health approach.
The ideal program would be dynamic, so that the focus could change along with the issues surrounding the epidemic. It would consider individual AOD problems as well as public health problems and would use all available indicators to assess the nature and scope of the problem and the populations involved.
Input would be obtained from key informants, including personnel working in STD clinics, those providing AOD treatment, and social science workers, and would be used to develop the system and identify the populations that will come into contact with it.
Gaps in services and needs that are not being met must also be identified. Public health authorities need to look at emerging health problems and predict what services will be required. For example, a community with an emerging crack cocaine problem should be aware that an increase in STDs and HIV is likely to follow. The personnel who work with populations in which crack abuse is prevalent need to have access to, and to be able to use, the screening instruments for AOD abuse and infectious diseases in order to identify individuals who are at risk for these problems.
Intervention for identified problems should begin with screening and assessment and move to prevention, early intervention, and treatment. The type of intervention must be determined by the nature of the population; for example, in a community with a low seroprevalence of HIV, prevention could be the strongest component. If an epidemic progresses in a community, however, the intervention should change. Thus, resources should be shifted as epidemics progress and change.
The screening instruments presented here can provide information about the needs in a given community. Screening results are an important form of feedback that should be incorporated into the continuum of care. Decisions about whether capacity should be increased and what levels and types of services are needed can be informed by the information provided by the screening instruments.
The screening instruments may also help to position a community to obtain additional funding for those needs that have been identified. Both screeners and trainers can contribute to the goal of meeting identified needs by developing strategies such as interagency agreements to bring in other human service organizations. In order for these collaborations to take place, however, turf issues must be minimized and cooperation and collaboration emphasized.
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