Making the Links Program

What is the Program?

The Making the Links program seeks to improve the health of gay, bisexual, and other men who have sex with men (gbMSM) by addressing internal and external barriers to wellness through short-term supportive counselling and service navigation within the community. It is a program of the Hassle Free Clinic, a community-based clinic providing medical and counselling services in all areas of sexual health in downtown Toronto. This program is fully funded by the Toronto Urban Health Fund.

The program consists of two streams:

1. The Prevention Program aims to address the underlying issues that gbMSM have that may be at the root of risk-taking behaviour through short-term counselling and referrals to other mental health and social services. The goal is to help clients engage in safer sex practices to remain HIV negative.
2. The Aftercare Program is for gbMSM who test positive for HIV at the Hassle Free Clinic or one of its satellites. This program provides clients with free and confidential short-term supportive counselling and/or referral coordination services as a way to help manage their HIV care. The primary goal is to facilitate access to HIV care through support and referrals, with counselling to address issues that might hinder sustained engagement in medical care.

The program is run by a counsellor/program manager who has a presence at the Hassle Free Clinic. Once clients are connected to the program, there is an initial visit between the client and counsellor to discuss the client’s needs, including counselling topics or referrals that are relevant to the client. The program includes up to eight counselling sessions (with some flexibility) and clients can be linked to medical and/or social services, as well as community resources, through the program. Transition out of the program is different for each client; however, the goal is to ensure that the client is supported and that their needs are met, as determined by check-ins during counselling sessions.

Why Was the Program Developed?

Making the Links grew out of the M2M Network, which the Hassle Free Clinic participates in. The M2M Network is a group of outreach workers dedicated to improving gay men’s sexual health. The group meets regularly to discuss issues and service coordination for gbMSM in Toronto. It was through this group that the need for more formal mechanisms to help gbMSM link to care was identified.

With the need identified by the M2M Network, the Hassle Free Clinic undertook program development. The Aftercare Program was developed on the basis of counsellors’ recognition of the frequent need of patients to have in-depth emotional support to take the first steps into care after testing positive for HIV (e.g., connection to medical services, disclosure). The Prevention Program grew directly out of clinicians’ recognition that people were presenting with difficult issues that could not be properly addressed at the time of testing within the setting of a busy sexually transmitted infection (STI) clinic. It was determined that gbMSM who tested negative and have ongoing risk-taking behaviours could benefit from a skilled, in-house counsellor and referrals to community services.

How Does the Program Work?

The Making the Links program is available to Hassle Free Clinic clients who are gbMSM identified. Referrals from external sources are also taken when possible. The program includes up to eight (with some flexibility) free, confidential, and individual counselling sessions; getting connected with a doctor and/or community supports; and ongoing support in navigating the social services and healthcare system.

Prevention Program

Clients who identify as gbMSM with high-risk sexual activities and who have tested HIV negative can connect to the program to help them remain HIV negative. Clients can self-identify if they feel that they are taking more sexual risks than they want to, or clients can be identified for referral by physicians or counsellors for their high-risk activities. If clients consent, their contact information is shared with the program manager/counsellor, who then connects with them by telephone or email.

The client and counsellor have an initial meeting where the needs of the client are discussed. The program requires completion of a formal intake form that includes a detailed history of the client’s mental and physical health, issues that the client would like to work on or discuss, as well as information on the topics of relevance to them. A consent form, privacy and confidentiality statement, as well as a policy and procedures document are also part of the intake process.

The Prevention Program addresses issues that lead clients to engage in high-risk sexual behaviours (e.g., history of trauma, experience of being bullied, internalized homophobia), while considering syndemic issues surrounding HIV. The Prevention Program often includes more sessions than the Aftercare Program because of the nature of the topics discussed (i.e., many clients access eight or more counselling sessions). Counselling topics often include:

• addictions;
• self-esteem and self-worth;
• sexual trauma and other types of trauma; and
• depression and anxiety.

Clients of the Prevention Program can also receive referrals to medical and/or social services and community resources, throughout their involvement with the program. Referrals that are commonly made as part of the Prevention Program include referrals for long-term therapy (e.g., private psychotherapy), referrals to counselling services specifically for lesbian, gay, bisexual, transgender, transsexual, two-spirit and intersex people concerned about their drug and alcohol use, referrals to support groups related to body image or addictions, referrals for pre-exposure prophylaxis, and referrals to various community-building support groups.

Through regular check-ins it may be determined that the client is ready to transition out of the Prevention Program but they may continue to need other forms of support. If clients require long-term services, the counsellor can help them to connect to these services. The counsellor can also refer clients into other programming in the community setting depending on what needs the client identifies, to ensure that clients are supported as they transition out of the program.

Aftercare Program

When a gbMSM client tests positive for HIV during a rapid test at the Hassle Free Clinic or one of its satellite clinics, they are offered the opportunity to be connected to the Making the Links program. Most of the referrals into the Making the Links program come from the Hassle Free Clinic and its satellite sites, although referrals from outside organizations are also accepted. Outside organizations have included immigration clinics, hospital emergency rooms, primary care offices, and other types of clinics where testing may be provided.

If a client consents, their contact information is shared with the program manager/counsellor, who then connects with the client by telephone or email. Clients are normally connected to Making the Links in less than a week; however, if the program manager is in the clinic at the time of testing, clients can be connected in person on the same day.

During an initial visit the client and counsellor discuss the client’s needs and the counsellor completes an intake form indicating what type of support the client is looking for. The initial conversation can also include a discussion of the types of supports the client already has and other important factors, such as insurance status; this information can be useful in determining the type of referrals that will be made. A consent form, privacy and confidentiality statement, as well as a policy and procedures document are also part of the intake process. 

Clients may not have a primary care doctor who is knowledgeable about HIV care, so the program seeks to link clients to a knowledgeable HIV clinician. The first appointment with an HIV primary care doctor is normally made within 10 days to two weeks after the client’s rapid HIV test. The program also connects newly diagnosed individuals with other health and social services, such as AIDS service organizations (e.g., AIDS Committee of Toronto, Toronto People with AIDS Foundation), mental health organizations (e.g., the Centre for Addiction and Mental Health, St. Michael’s Hospital), the HIV & AIDS Legal Clinic of Ontario, services related to income assistance and drug coverage, and community resources that are relevant to clients, through warm referrals (e.g., connection via an email introduction).

The Aftercare Program includes post-test counselling. Counselling topics vary and are geared towards the client’s needs identified in the first session. In the Aftercare Program, clients will often only require one or two sessions to speak with the counsellor and be connected to the needed health and social service providers. If there are additional issues that require the support of a counsellor (e.g., feelings of isolation), clients can see the counsellor for additional sessions. Counselling topics can include:

• a check-in with clients after diagnosis to see where they are at;
• providing support for clients to talk through their feelings and thoughts, as well as the opportunity to offer education and reassurance;
• discussing treatment approaches (e.g., medications, drug insurance questions) and what to expect during the first two months; and
• discussing how the client’s diagnosis is affecting them.

The transition out of the program occurs as clients are referred to the services that they require. The program includes check-ins, which help to determine if the client is feeling supported and whether they would like additional supports. Referrals to medical and/or social services as well as community resources occur throughout the client’s connection with the program. Transition out of the program can be different for each client. The counsellor follows up with clients at three months, six months and one year after the start of HIV treatment to assess and assist with barriers to care.

Required Resources

One full-time staff member acts as the program manager and counsellor for the Making the Links program. This staff person is a registered psychotherapist; if the program is established in other settings, it should be staffed by someone with counselling/social work training. The position is supervised by the clinic director. Other staff members provide support for the program such as liaising with funders, assisting with reports, and providing logistical support (e.g., booking appointments).

In addition to an experienced counsellor with knowledge of the population served, the program requires:

• quick access to counselling services and support, as well as visibility within a clinic; and
• connections with external clinicians and programs for referrals.

The ability to view clients holistically, while acknowledging the complexity of each client and circumstance, is also an important aspect of the program.

Challenges

• Linking clients to services when they are on a visa (i.e., visitor, student, or work). There are difficulties in establishing consistent and sustainable care for individuals on visas including access to doctors, lab tests, and medication, which can lead to significant service gaps. Staff efforts to connect clients who do not have permanent status and/or health coverage (e.g., Ontario Heath Insurance Plan [OHIP] coverage in Ontario) to services can be time and resource intensive.
• Finding mental health services for the gbMSM population. There are a lot of mental health needs for gbMSM and there are not always readily available services. Even if mental health providers are available, affordability can be issue.

Evaluation

From January to June 2018, 101 clients were seen through the Making the Links program, with a total of 202 clinical encounters and 87 community referrals.

• Fifty-nine clients accessed the Prevention Program for psychological assessment and short-term counselling services (up to 10 visits) with a total of 139 clinical encounters.
• Forty-two clients accessed the Aftercare Program with a total of 65 clinical encounters. Most clients required one or two sessions and most clients were connected to an HIV primary care doctor within one or two weeks of their rapid point-of-care reactive test.

The most common presenting issues in the Prevention Program were:

• anxiety or stress (89%);
• relationship issues (81%);
• family issues (75%);
• issues related to self-esteem (72%);
• depression or sadness (67%); and
• loneliness or social isolation (67%).

The most common presenting issues in the Aftercare Program were:

• acceptance of diagnosis (84%); and
• HIV disclosure (84%).

Clients who participated in the Making the Links program from January to June 2018 were most commonly 25–34 years old; approximately 35% of clients in the Prevention Program and approximately 60% in the Aftercare Program fell into this age range. In terms of ethno-cultural background, clients served in both the Prevention and Aftercare programs were predominantly white, 46% and 36%, respectively. For the Prevention Program, East/South East Asian and South Asian men were the next highest groups served, both at 12%. For the Aftercare Program, East/South East Asian and Latino men were the next highest groups served, both at 21%.

A survey of Making the Links program participants was completed in 2014 and found that:

• approximately 96% of clients strongly agreed or agreed that their counsellor created a safe space and respected who they are as an individual; and
• approximately 70% of clients strongly agreed or agreed that their counsellor helped them to connect to community resources.

Lessons Learned

• Use of immediate and on-site support, using a medical model with allied health professionals, improves linkage to care. Before the Making the Links program was implemented, post-test counselling and information was provided to clients following a positive HIV diagnosis, but with no formal follow-up mechanism. The approach used with the Aftercare Program allows for follow-up.
• The need to meet clients where they are is essential. This can mean short wait times from referral to first meeting (i.e., usually less than two weeks), while also cutting down barriers to access mental health care, especially when people are in crisis.
• Linking recently diagnosed clients to HIV primary care doctors and other AIDS service organizations rapidly is critical. Research has shown that when people are linked to primary care immediately after diagnosis they have better treatment adherence.
• It is important to get at the root of why clients may engage in high-risk sexual behaviors. Issues such as isolation, low self-esteem, trauma, homophobia, racism, depression, lack of community, and other negative life experiences can affect high-risk sexual behaviours. Addressing these issues is essential to reducing high-risk sexual behaviours.

Program Materials

• Prevention Program intake and consent form
• Aftercare Program intake and consent form
• Prevention Program referral form
• Hassle Free Clinic – Making the Links - Privacy & Confidentiality Statement
• Hassle Free Clinic – Making the Links - Policy & Procedures

Contact Information

Amy Lin, Program Manager/Counsellor
Hassle Free Clinic
66 Gerrard Street East, 2^nd floor
Toronto, ON  M5B 1G3
Tel: 416-922-3549 x128
Email: Amy@hasslefreeclinic.org