Florida Department of Health in St. Lucie has approximately 186 employees. It provides public health program and services: Women, Infant and Child, Environmental Health, School Health, Healthy Moms and Babies, Sexually Transmitted Infections, HIV/AIDs, Ryan White, TB, EPI, Vital Statistics, Health Education Tobacco, Child Safety, Clinic and Dental. St. Lucie County, Florida has population of approximately 328,297, comprised of 55.9% white, 21.4% black, 19.9% Hispanic, 4.4% other, age 19 - 64 49.2%, 65+ 24.7%, <18 24.5.  The medium income is $52,322, medium house cost is $186.900 and medium rent is $1,185. The households with computers are 91.9% and with access to internet 84.7%. Persons without health insurance, under age 65 years is 17.9%. Persons in poverty 10.5%. (U.S. Census Bureau 2019).

The restrictions due to COVID19 from social distancing, closure of offices and limitations of walk-ins has greatly reduced the number of persons being tested and counselled for HIV/AIDs and/or STDs, potentially leading to an increase in infection rate within the county. The HIV/AIDs team created and implemented a grassroots "Pop Up Drive Thru" process to try and capture more folks who wouldn’t come to the office for fear of catching the COVID19 virus. The HIV/AIDs team, collaborating with community partners set up various locations throughout the county to offer testing and counseling, as well as additional testing depending on the partner. Although, it was named “drive thru”, to ensure accessibility for all, there were procedures and processes set up for those without a car to be able to walk-up and get tested.

The goal of this initiative was to increase access to HIV/AIDs testing and counseling services. The objective was to offer a safe accessible way for anyone who wanted to be tested in which made them feel safe and ensure their confidentiality. The locations and community partners were chosen based on specific neighborhood(s) identified as vulnerable area(s). The grassroots approach allowed for the community to share the information by word of mouth, support the initiative, increase awareness, as well as distribute flyers amongst their local neighborhood. 

Due to COVID19, outreach events were not available from 3/2020 thru 08/2020. After analyzing and recognizing the need for these services, the HIV/AIDs team created the 1^st outreach on 09/29/2020, “Pop Up Drive Thru Event”.  During this event they tested 5 individuals, provided education and gave out condoms to 28 individuals. The HIV/AIDs team learned that the community is very cautious and many declined testing due to COVID19 social distancing. In their last event 12/17/2020 in Fort Pierce, they were able to test 10 individuals for STDs, HIV/AIDs and Hepatitis C. The hope is that the more events they do, locals would start feeling more comfortable, resulting in more people being tested. 

The HIV/AIDs team felt that the initial results were successful in being that there were some participants.  The overall findings are still ongoing and will continue to be evaluated on locations, accessibility, number of participants and with community partners and on additional services. 

From March 2020 through July 2020, one could only be tested or counseled by appointment only.  The HIV/AIDs team was aware of the lack of accessibility with the greatly reduced number of people being tested and worried this would create another crisis with an increase in infection rate of HIV/AIDs, STDs and Hepatitis. This was especially challenging since members of the community were very apprehensive of coming out to be tested for fear of catching COVID19.

Due to the COVID19, restrictions that were put in place prohibiting walk-in testing and counseling of HIV/AIDs, STDs and Hepatitis and restricted to appointment only greatly reduced the number of people having access to this service, potentially leading to an increase in infection rate within the community.  The consequential effects on the individual, family and community could lead to a burden to the individual with complex medical issues, on support from family members and stressing resources of the community to help treat and care for these individuals. All of which could be a strong preventative measure in reducing amount of infection by getting out into the community to test and counsel as many as possible during this time.   

The HIV/AIDs team tests, treats and educates throughout 4 counties, known as Area 15. These counties cover: Indian River, Martin, Okeechobee and St. Lucie. Prior to COVID19, the HIV/AIDs and STD departments offered counseling, testing for individuals by walk-ins and through agency partner sites located within several areas of each county.  The age group with the highest proportion of persons who received an HIV diagnosis in 2019 was 20-29 years of age. Okeechobee with 105-246, Indian River and Martin counties with approximately 247-498 infected people and St. Lucie county having over 1439 diagnosed. Persons who received an HIV diagnosis in Florida by mode of HIV exposure: 59% Male-to-male sexual contact, 19% female heterosexual contact, 3% make injection drug use.  Race: Black 38%, Hispanic/Latin 36%, White 24% with 79% males and 21% female. (Florida Charts).

The “Pop Up Drive Thru” outreach was not in place, although there were events scheduled throughout the year.  During pre-COVID19, traditional testing was commonly used (blood draw, 15 min rapid test), social distancing not being an issue. During COVID19 the team made the decision to utilize the 1 min rapid test, utilizing the free HIV/STD testing voucher, HIV oral swabs, and/or offer home test kits-self testing (for individual at risk) following all provided CDC safety guidelines protocols. For accessibility, drive thru testing was provided so clients could stay in their cars, as well as a specified area was setup for walk-ups both following CDC guidelines. The grassroots approach allowed locals to get the event information out by word of mouth. This also allowed local partners to support the event within their own neighborhood promoting safe and confidential testing. Every event followed strict CDC guidelines for everyone’s safety, hoping to mitigate any fear of catching COVID19 from a public event. 

Resources in implementing the COVID19 “Pop Up Tent Drive Thru” had its challenges. Staff, for one, are also required to respond to emergency threats, therefore have dual roles, both HIV/AIDs and the then responding to COVID19, limiting their time and efforts. Another challenge was the logistical support: IT, Tents, PPEs and supplies which required relying on support teams who also have dual roles during this pandemic. While setting up events is not new to the HIV/AIDS team, however, during COVID19 has brought about limited resources. They do this with the foresight in trying to prevent another crisis during this public health criticism, which is not only commendable, courageous and innovated - it is public health at it’s best.  

Evidence based: Rapid HIV Testing in Outreach and Other Community Settings – United States, 2004-2006, CDC, MMWR November 30, 2007. “To increase the proportion of persons aware of their HIV serostatus, CDC launched the Advancing HIV Prevention initiative in 2003 (4). One strategy of the initiative is to implement new models for diagnosing HIV infections outside medical settings.” “This project demonstrated that rapid HIV testing in a range of settings can effectively target multiple populations at high risk for HIV infection. Offering rapid HIV testing in outreach and other community settings provides opportunities to identify HIV infections and to link persons with positive test results to prevention and medical care.”

The goal and main objective are to collaborate with local providers, agencies assisting in organizing events for local community neighborhoods providing a safe and confidential alternative site for testing. This is considered a grassroots initiative, building stronger relationships with local businesses, providers, community organizers and schools bringing about awareness of how important to a community to test and counsel it's residents on HIV/AIDs and STDs helping to prevent the spread of infections. In addition to test and treat, the partnerships are also vital in being able to provide additional services. An agreement between FDOH-St. Lucie and partner(s) share in the planning and implementation process prior to any event working out details and for services to be provided.

The HIV/AIDs are aware of the benefits of reaching out to the community. Pre-COVID19, outreaches were scheduled throughout the year, however, since onset of COVID19 and the limitations, once permitted the team felt it best to partner with local neighborhoods for continuation of services. The power of community partnership explained in national HIV Testing Day: The Power of Partnership, Greater Than AIDs, HIV.gov November 22, 2019. “Public-provide partnerships have long been a staple of globe health responses.” One benefit being “… for local agencies to engage with individuals in a familiar setting...” “…an opportunity to ask questions and find out about the latest on HIV from experts in an accessible,  low-stress environment.”  For FDOH-St. Lucie, community partners are invaluable, from helping get the word out and assist in reaching vulnerable populations to providing resources. So, although, the outreach events are not new, doing them during COVID19 we felt was an innovated grassroots approach offering a drive through approach.

Steps for implementing “Pop Up Drive Thru” events: On the day of event, ensure there is required and an adequate amount of PPE.  Setup tents, equipment and mark off areas for cars and walk-ups. Everyone is required to wear a mask at all times. Once tested, fill out necessary paperwork, once services consented have been signed, continue with form 1628. If multiple passengers are to be tested, they must vacate the care and wait in a safe area where confidentiality will be provided for all the passengers. Once testing concludes, provide client with educational brochures and condoms. If required, based on weather, client is not comfortable with having tester reach into car they will be handed a self-test, given instructions on how to swab themselves and seal it, then return during their visit. If client does not have a vehicle, they will be directed to an area, approached in same manner as in a car, either swabbed by personnel or self-swabbed. If a reactive result from a rapid test, if close to health department guide them to lab, if too far, blood sample will be drawn to be sent to state lab. At this time, they will also be screened for syphilis, chlamydia and gonorrhea. Make an appointment for Test & Treat for same day or next day at the latest.

On September 29, 2020, FDOH-St. Lucie, HIV/AIDs department collaborated with Mary Sirmons, the Co-Chair of Area 15 HIV/AIDs Comprehensive Planning Network and Chair of the Ad Hoc Outreach Committee. She provided 1628 pre-counseling and community education services.

On October 10, 10, 2020 FDOH-St. Lucie partnered with the 1^st Annual Breast Cancer Awareness Event in Okeechobee County: During this event we collaborated with the Florida Mobile Mammography Driven to Defeat Breast Cancer Team and the Okeechobee County Fire Rescue Department in Recognition of the Breast Cancer Awareness.

On October 17, 2020 Community Health and Wellness Fair Outreach Event. During this event HIV/AIDs department collaborated with the local community The Life Shift Church, Florida Community Health Center, Florida OneBlood, Council of Aging of St Lucie County and the Treasure Coast Hospice. During this event the community was able to access health screening services: -Blood Pressure – Blood Glucose – BMI – O2 – Pulse – Covid19 – HIV/STDs screenings – Blood and Platelets Donations – Flu Shots.

On December 17, 2020 Our event was held at the Pinewood Park in Fort Pierce, in recognition of World AIDS Awareness. Mary Sirmons the Co-Chair of the Area 15 HIV/AIDS and local ID provider were invited.  

Our quality improvement approach follows the RE-AIM approach (Adoption, implementation, maintenance, reach and effectiveness) using evidence-based programs, which we had cured for our pre-COVID outreaches. We collaborated with local partners, and/or participated in an already existing event. We accessed staff, who were already cross trained from several departments in participating due to lack of resources with response to COVID. Documentation of consent for services, while manual, were scanned and attached to electronic file, as well as 1628 forms. Internal policy and specific flow charts were developed to ensure consistent delivery of services during the event. Feedback from target population was word of mouth. Lesson learned: a questionnaire should be set up for either the tester to input electronically or an iOS platform survey pushed out to targets phone as an option while incentives/condoms were being handed out. A survey will be sent to community partners, assessing quality of event, lessons learned, possible improvements.

The staff of both departments: HIV and STI noticed a reduction in the amount of people being tested since onset of COVID19. The restrictions resulting from social distancing, closure of offices and/or limiting of walk-ins, reduced the number of in person testing and counseling.   The HIV/STI teamed up and created a grassroots "Pop UP Drive Thru" for anyone needing/wanting to be tested and/or counseled. They collaborated with community partners and when possible teamed up at local events in which they provided additional services at the same time as testing and counseling throughout the community. The success is based on being able to test and counsel residents within our community. We do not know if we saw more clients than the traditional walk-in testing and counseling but do know we would not have reached the ones we did given the limitations.   The public health impact of practice is well documented as to why we need to do testing, treatment and counseling for both STI and/or HIV. Evidence shows it lowers transmission, infection and associated health risks. The HIV/AIDs team targeted efforts in locally owned and known spots in the counties and offer services: barbers shops/ beauty shops, small convenience grocery stores: Mexican stores (Hispanic population), local bars, LGTQ bar hang outs, homeless/IDU hang outs. Establishing relationships with businesses and churches may also reach older audiences. These “Pop Up Drive Thru” outreaches are being held in counties and neighborhoods where it is a high-risk area or hot area. 

The HIV/AIDS team dedicated their time in adapting and finding new ways to make testing available for our community during COVID19. The goal is to provide education and inform the community about our services through outreach events or by walk-in at the CHD. During the past outreach events we learned to identify and target vulnerable populations (homeless, low income populations and IDU population). The HIV/AIDS department also understands that each event is unique bringing its own set of challenges and successes.  Along with the understanding that services need to be accessible to all and that safety guidelines are of most importance during this pandemic.  

Resources were reallocated from in-house services to primarily outreaches. Stockpiles of PPE were reallocated to the outreaches and staff was able to use their exiting IT equipment/air cards. Manpower was the most challenging, very limited since their priority is to respond to COVID19 first, leaving a skeleton crew most days.

HIV/STDs testing have been well-received by our participants and local providers. These events experiences offer us an important lesson and understanding of the HIV/STI community risk and the importance of making these services available in time of COVID19.  Our “Free HIV/STDs Testing Voucher” was well received by the community and is constantly used in every outreach. In order to adapt to the time of COVID19 a “Free HIV/STDs Testing Voucher” was created for clients that refused testing due to COVID19 social distancing. This voucher allows the person to receive a free HIV and STDs panel test at one of our two county health department clinic locations CHD by Walk-in or appointment.