Background

The human immunodeficiency virus (HIV) and sexually transmitted infections (STI) pose a danger to one’s health and well-being, including long-term health problems if left undiagnosed (HIV.gov., 2021). Data from the CDC estimates that one in every 500 college students is infected with HIV as of 2020. By the age of 25, when nearly half of all Americans aged 18–24 years are enrolled in college or graduate school (Hanson, 2022), one in two individuals will contract an STI (Johnson & Jackson, 2021). In a survey conducted for first-year students at primary college institutions, two in five were tested for HIV at least once in their lifetime (Caldeira et al., 2012). Hence, access to testing services to gain knowledge of one’s status is a crucial part of knowing one’s HIV status and overall health (Subbarao, & Akhilesh, 2017). Without proper access to HIV/STI testing over the course of a student’s experience at a college, there may be increased susceptibility to HIV/STI infections or transmission in student sexual networks. Even more so, where individuals are tested is an important first engagement with HIV/STI services and subsequent routine testing. For instance, clinical settings, such as a hospital or primary care provider office, might offer different resources than an LGBTQ+ community center or sexual health-specific clinic (Lee et al., 2014). These comprehensive cultural resources may increase the likelihood of return testing or engagement with different healthcare resources at the location.

The COVID-19 pandemic created massive disruptions to HIV/STI testing services across the country and at the University of Michigan. Colleges and universities across the state of Michigan suspended services or reserved testing for only those who were symptomatic for HIV or STIs. The current HIV/STI infection rates among college students and the need for testing establish the importance of reopening HIV/STI testing services at the Spectrum Center and Wolverine Wellness.

Studies have shown that a competent and robust health workforce supports better HIV program outcomes (Akoku et al., 2022). The AIDS Education and Training Center Program (AETC) in 2016 emphasized the importance of strengthening the HIV workforce, highlighting “the need for comprehensive strategies to ensure a healthy pipeline,” including the need for collaboration (AETC Southeast, 2016). AETC states a priority of “recruiting [linkage to care] professionals that are culturally and linguistically concordant with the populations they service.” Therefore, the collaboration between the Spectrum Center and Wolverine Wellness and Unified HIV Health and Beyond (UHHB) is essential to scaffolding necessary sexual education and HIV/STI testing.

Field Background (Site, Location, Duration)

The setting of HIV/STI test counseling for these field notes took place in the United States, the only developed country with an ongoing HIV epidemic (Straube, 2021). The state of Michigan in 2020 had an average rate of new HIV diagnosis of 6.1 per 100,000 people (CDC, 2022), and rates of STIs have steadily increased since 2016 (MDHHS, 2022). There are no specific testing data for HIV/STI rates at the University of Michigan, but in February 2022, healthcare professionals reflected on the heightened negative social perceptions of STIs on campus (Kassa, 2022). Before this, I was certified as an HIV/STI test counselor in May 2021 after completing the last of three virtual training sessions by the Michigan Department of Health and Human Services (MDHHS) in Counseling, Referral, and Testing (CTR). Subsequently, I trained in-person at UNIFIED–HIV Health and Beyond (UHHB), the community-based organization providing HIV/STI services for Spectrum Center and Wolverine Wellness, in August 2021. I led the HIV/STI testing services as the Lead HIV/STI Test Site Counselor in a clinical role, working directly with students and community members for testing. Prior to testing services resuming in the Fall 2022 semester, Spectrum Center staff, specifically those working the front desk and phone, were educated on how to discuss HIV/STI testing service offerings and what information needed to be referred to trained HIV/STI test counselors. For instance, Spectrum Center staff could tell individuals when and where testing took place, but not, for instance, provide medical advice to whether or not a client should be tested. Testing resumed at the Spectrum Center on National Coming Out Day, October 11th, 2021, providing free confidential culturally competent walk-in HIV/STI testing services to not only students, but anyone in the community. HIV/STI testing services were provided every Monday apart from academic breaks and closures based on staffing availability during the evening at the Spectrum Center. While Spectrum Center testing services were walk-in only, Wolverine Wellness remains appointment based. Testing was conducted for both Fall and Winter semesters with a temporary pause in services during May 2022 at the Spectrum Center to adjust for summer hours and demand for testing from a smaller student population on campus, and services remained the same at Wolverine Wellness. With this, appointment-based testing was initiated at the Spectrum Center to accommodate all individuals seeking to get tested, but not to burden the Center’s staff with open periods of operations from the school year. Walk-in testing at the Spectrum Center subsequently resumed with the beginning of the Fall 2022 semester. However, a delay in the initiation of services was seen during the first week of classes based on staffing shortages and determination of operating hours, for which HIV/STI testing may be conducted outside these hours.

Programming for HIV/STI-related topics was provided on prominent recognition days, such as World AIDS Day in December and National Youth HIV/AIDS Day in April. These recognition days serve as unique opportunities for community-based organizations and advocacy groups to tailor events and programming to populations impacted by the cause. Notably, the Spectrum Center opened its doors for testing services on a Sunday to accommodate National Youth HIV/AIDS Day with success in the delivery of testing and knowledge around the importance of sexual health for youth populations, including college students (Spectrum Center, 2022). The emerging Monkeypox (MPV) crisis in the United States (Sutfin, 2022) prompted a collaborative event between the Spectrum Center, MDHHS, and UHHB to hold a lunch-in conversation regarding the most up-to-date information for the virus, including access to prevention tools, treatments through the form of vaccines, and methods of group/self advocacy to affirm the ongoing struggle of minoritized populations in public health.

Observations

1. Sexual education of students

   1. The inherent geographic and cultural diversity of the University of Michigan establishes a spectrum of sexual education knowledge among students who engage with HIV/STI testing services. Some individuals were educated with comprehensive sexual education, covering methods of HIV/STI prevention, consent, and contraception. However, many students, especially those originating from the state of Michigan, did not receive sufficient sexual education, including pertinent education on HIV/STIs (SIECUS, 2021).

2. Sexual history of students

   1. The sexual history of students can vary immensely. Periods of sexual exploration are not unique to college students but are distinctly present for younger individuals discovering their gender and/or sexual identities (Bishop et al., 2020). HIV/STI testing services at colleges/universities uniquely serve young individuals who have not engaged in sexual activity or who are re-engaging in sexual activity after periods of abstinence or monogamy. Sexual history informs a student’s decision to seeking HIV/STI testing, meaning updated sexual education and tools must be available to ensure improved sexual practices.

3. PrEP among students

   1. Pre-exposure Prophylaxis (PrEP) is a proven HIV prevention medication, either orally or injection administration, that prevents HIV infection upon exposure (Holmes, 2012). Each client tested at Spectrum Center & Wolverine Wellness is screened for PrEP need and eligibility. Although PrEP is often of interest for susceptible student priority populations, there are accessibility challenges. For instance, if a student is on their parent’s insurance and does not feel comfortable having PrEP show up on an explanation of benefits, there are few options available for accessing PrEP (Hall, 2022). Additionally, a small but important population on campus does not have insurance to cover PrEP medication or any other medical services (Bauer-Wolf, 2018). Because HIV/STI testing services are free from federal and state grants through UHHB, insurance is not required nor is any insurance taken.

Recommendations

The sustainability of free HIV/STI testing services is uncertain for the Spectrum Center and Wolverine Wellness. Currently, only one individual operates the testing facilities through the University of Michigan with occasional support from UHHB paid staff at Wolverine Wellness. HIV/STI test counselors at the center are volunteers, and unpaid, contributing to the difficulty to find individuals to work the positions. Additionally, there is a lengthy three-part training process to become an HIV/STI test counselor certified through the state of Michigan. Two trainings require ample time during business days to attend training, which coincides with a typical school day, preventing students who are interested in becoming a test counselor to be fully trained. We need a more streamlined process of training individuals, specifically students, and financial compensation to improve the availability of testing. A streamlined training would reduce time-burden on the trainee and cut-down on the total time it takes to become an HIV/STI test counselor. Free HIV/STI testing was nearly suspended in 2019 by University Health Services, yet student advocacy prevented such a measure (Nouhan, 2019). We cannot guarantee free HIV/STI testing at the University of Michigan, by which staffing support from culturally competent students is necessary to support better sexual health on campus. There are gaps in service the can be supplemented through an increase in staffing and simplifying the process to become a trained HIV/STI test counselor.

Conclusion

HIV/STI testing services at the University of Michigan’s Spectrum Center and Wolverine Wellness provide a plethora of tests to students and community members each year through walk-in and scheduled appointments, which further the knowledge of germane sexual health education. There are many benefits to free testing through the centers including (1) increased knowledge of sexual education and preventative tools; (2) culturally competent gender and sexual affirming services; and (3) increased PrEP uptake among college students. However, there are essential steps needed to sustain free HIV/STI testing services including (1) streamlined training sessions and (2) reasonable compensation for test counselors. My personal experiences as an HIV/STI test counselor at the University of Michigan have informed better workflow processes and elucidated best practices to engaging student populations. After re-establishing testing services from the height of the COVID-19 pandemic, there is a demand for HIV/STI testing among student and community members, and necessary problems to address for the future.