The PACT Project

In Delivery on October 11, 2009 at 11:25 am

Health Promotion from Haiti to Boston

Lulu Tsao, Staff Writer

Courtesy of PACT

Courtesy of PACT

As she talks about the recovery of one of her clients, Magalie Lamour-Médé’s voice is filled with warmth and pride. When they first met, Lamour-Médé’s client was “literally at death’s door.” Struggling with HIV/AIDS, she weighed only 84 pounds and had difficulty adhering to her medications. After joining the Prevention and Access to Care and Treatment project (PACT), the patient not only regained weight and suppressed her viral load, but also improved her relationship with her teenage daughter and overcame substance abuse.

As one of PACT’s community health promoters, Lamour-Médé serves some of the most marginalized AIDS patients in the Boston area. A joint project of the Brigham and Women’s Hospital and the nonprofit Partners in Health (PIH), PACT began in 1999 to assist patients who have poor access to and utilization of healthcare. Its community-based model comes from PIH’s work in Haiti, where accompagnateurs provide directly observed therapy (DOT) and social support. Here in Boston, PACT’s major initiatives—harm reduction, health promotion, and DOT—seek to address AIDS from prevention to care.

At the simplest level, PACT’s work is about building relationships. Because they share clients’ cultural and linguistic backgrounds, the staff feels they truly understand the social inequalities that interfere with adherence. Health promoter Jason Villarreal describes his day-to-day work as “walking with people.” He explains that such “walking” brings him to doctors’ offices, social services, and into patients’ homes. Here, he can “meet people where they’re at” by learning about the circumstances of their realities and then providing tailored assistance with their HIV treatment. In the case of one of his colleagues, “walking with people” can even mean sprinting through the hospital after a client is dropped off on the wrong side of the building. PACT’s staff applies this “whatever it takes” approach to helping its patients not only with HIV treatment, but also with issues related to mental illness, unemployment, substance abuse, domestic violence, poverty, and homelessness.

A major goal of health promotion is to complement the medical system by building bridges between patients and their physicians. Jessica Aguilera-Steinert, director of client services, describes health promoters as “hav[ing] a foot in both worlds—the medical world, with its education and language and ‘whiteness’—and the world of the patient.”

Specifically, health promoters understand and can translate both the language of the physician and the concerns of the client. While many physicians recognize that they themselves cannot conduct home visits, most do not actively seek out health promoters’ opinions. When physicians cannot identify reasons for non-adherence, health promoters help illuminate patients’ other sources of stress: threat of eviction, difficulty paying bills, or problems with family, to name a few. Villarreal has assisted in such a way, but notes that he was “stunned” at a recent case conference at Massachusetts General Hospital when the attending asked directly for his input.

According to PACT’s staff, the success of their program stems from a holistic view of the nonadherent patient and the chance to truly connect with their clients. Providers have described feeling frustrated that, no matter how they try to encourage patients, many do not seem to care. But, Lamour-Médé explains, “Often, people are screaming for help, screaming in the sense that ‘I’m not going to take these meds because I don’t mean much to society.’”Courtesy of PACT

PACT not only addresses such health and emotional needs of patients, but also shapes its mission around empowerment. Aiming to encourage patients to advocate for themselves, PACT’s health promoters are trained to assist without creating excessive dependence in patients. Villarreal explains, “I tell people, my goal is to work myself out of a job.” If a patient is able to navigate an appointment independently, Villarreal is pleased with his work and optimistic that further adherence improvement will succeed.

Clinical data reflects these successes: on average, patients’ CD4 counts increase by over 100 in one year. Cost reductions also accompany these health improvements, with medical savings averaging $18,000 per year for an increase in CD4 count from less than 50 to over 200. The impact of PACT’s philosophy and delivery of care extends beyond these numbers, to increased healthcare utilization, mental health and substance abuse treatment, better relationships with families, and disclosure to partners.

While PACT’s model is grounded in the local, it is expanding geographically and clinically. Director Heidi Behforouz and Aguilera-Steinert have trained personnel at hospitals, universities, and healthcare organizations in Florida, New York, and Ohio. PACT’s Dorchester site receives many visitors, ranging from nurse practitioners from Michigan to Jamaica’s ministry of health. Within Massachusetts, a pilot project is funding health promotion services to address other chronic diseases like diabetes. While sustained funding remains a challenge, the widespread recognition and interest in PACT’s work contributes to its energetic, hopeful atmosphere.

Another organization might be overwhelmed by the combined demands of direct service and technical assistance, but PACT’s entrepreneurial spirit enables it to do both. As Aguilera-Steinert states simply, “there’s no secret—it’s a good intervention with very, very caring people.” With a powerful and flexible community-based model, their dedication is poised to reach patients across the rest of the country.


Behforouz, Heidi and Aguilera-Steinert, Jessica. “Health Disparities in Our Own Backyard.” Replication training. St. Luke’s Roosevelt Hospital. September 2008.

Aguilera-Steinert, Jessica. Personal interview. 12 March 2009.

Villarreal, Jason. Telephone interview. 19 March 2009.

Lamour-Médé, Magaile. Telephone interview. 19 March 2009.


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