Bathhouse and “Know On The Go” Mobile HIV Testing Projects
Out of the Clinic and Into the Community
Understandably, not everyone feels comfortable walking into a sexual health clinic or asking their doctor for sexual health-related services. Concerns of privacy, stigma related to sexually transmitted infections (STIs) and HIV, and accessibility are just some of the reasons why gay, bisexual and other men who have sex with men (MSM) may not access sexual health services and education in clinic-based locations. A 2011 community consultation report by the Health Initiative for Men1 suggested that for MSM in Vancouver this can be the case: out of almost 100 men surveyed at outdoor sex venues, two-thirds expressed a lack of sexual health information, less than half reported male sex partners to their doctors and three-quarters were in favour of offering HIV and STI testing at outdoor venues.
Given that in 2011 gay, bisexual and other MSM in Vancouver represented more than 60 percent of new HIV infections in Vancouver, the Vancouver STOP Project employed a strategy used in cities across North America to provide sexual health services to MSM who might not otherwise access them: bathhouse testing and mobile HIV testing.
Taking Services to the Community
Both the bathhouse and mobile testing initiatives were implemented through the leadership of the STOP Outreach Team, an interdisciplinary clinical team that works across the city of Vancouver to expand HIV testing and engagement in care. The mobile testing project was developed in partnership with YouthCO, a community-based agency in Vancouver. These initiatives involved the creation of mini satellite sexual health clinics where clients can access a full range of HIV and STI testing, treatment and counselling services from a registered nurse. These services are similar to what clients can expect to find at a sexual health clinic, but outside of a traditional clinic setting. Both projects provide essentially the same services by STOP Outreach Team nurses. The primary difference between them is where the services are offered: one is in Vancouver bathhouses; the other is in multiple, changing locations via an outreach van.
Bathhouse-based HIV Testing Project: In this initiative, a STOP Outreach Team nurse worked with bathhouse owners to set up and provide services in a room converted into a small clinic in each bathhouse. Three bathhouses in Vancouver participated.
Mobile HIV Testing Pilot Project: Dubbed “Know on the Go” (KOTG), for this initiative the STOP Outreach Team partnered with YouthCO to deliver services. YouthCO converted a van into a clinic on wheels, promoted the project, determined times and locations to situate the van for outreach and provided outreach workers to inform and educate people when the van was on location.
The following programming element highlights how the STOP Outreach Team approached the provision of sexual health services in unconventional locations.
Working with – and in – the community
Moving sexual health services from a clinic into community-based sites requires answering a significant number of questions: How will the community perceive the service? Will people access the service? How can services be provided without having them be seen as coercive or pushy? The answers to these questions were difficult to predict and so numerous strategies were employed to ensure the community received the services as well as possible.
To determine how to best meet the HIV testing needs of gay men and other MSM, the Vancouver STOP Project partnered with a number of leading gay men’s health organizations and community representatives to form a Gay Men’s Reference Group. This group was tasked with the exploration of new strategies for outreach and service provision.
The group highlighted a number of priorities to be taken into consideration when providing site-based services, such as ensuring the privacy of clients, providing culturally safe services and maintaining the same standard of care as a clinical setting. These were reflected in a document titled “Principles for Provider-Initiated Testing External to Healthcare Venues” that the Vancouver STOP Project used to help structure these services. For more information on these priorities, please see below.
Getting Set Up
The STOP team and YouthCO aim to provide the same quality, level and variety of services through their community-located testing services as would be provided in a clinic. These include the ability to test and treat a range of STIs and offer HIV testing with rapid point-of-care (POC) technology as well as standard blood draws. Two key issues had to be addressed to ensure this would be possible: first, how to create mini satellite clinics in nontraditional settings; and second, how to develop strong relationships with business owners and other stakeholders, such as park staff, at outreach locations.
Creating Satellite Clinics
Providing comprehensive sexual health services via satellite clinics required overcoming a number of logistical challenges that included ensuring access to adequate clinical supplies onsite and establishing a process to get test samples to a lab. The Vancouver STOP Project addressed this issue by working from an existing, standard sexual health clinic run by Vancouver Coastal Health. The mini satellite bathhouse and mobile clinics rely on this existing infrastructure to obtain necessary supplies, such as POC tests and treatments such as antibiotics. After work shifts are completed at the satellite clinics, test samples are taken either directly to the lab for testing, or to the sexual health clinic where they are batched with all of the samples obtained that day at the clinic.
Beyond a few logistical challenges, such as issues of what to do with samples that were taken after the lab closed, STOP Project nurses found they had the time and space to provide more in-depth, broad services to clients than they might have had in the clinic. In clinic-based settings, where there is often a higher patient load, services are time limited and therefore nurses must be more focused on providing a discrete set of services. Providing services in a non-clinic environment, however, enables nurses to spend longer with their clients and discuss many of the broader issues and health concerns impacting their lives, such as substance use, mental health or other non-sexual health-related concerns that may be more urgent for them.
For both the bathhouse and mobile testing projects, building strong relationships with the outreach sites was critical. A significant investment of time and relationship building over multiple meetings was required to ensure the community would receive the services as positively as possible.
When an outreach site was selected for the mobile testing van, YouthCO reached out to the venue (or park officials when at public parks) to let them know about the service to ensure there would be a good reception. Similarly, STOP Outreach Team nurses developed strong relationships with bathhouse owners.
One of the most common concerns voiced through the relationship-building process was the potential for negative community perceptions, in that providing services onsite would “ruin the fun” for clients. Ensuring a passive approach to service provision was an important aspect of addressing concerns about invasion of space. Rather than actively approaching people and encouraging testing, nurses simply make their presence known, either through signs, announcements on the bathhouse PA system or simply by their physical presence when in the KOTG van.
Relationships with bathhouse owners have continued to improve as they perceive the nurses as an “added service” demonstrating their interest and investment in their community’s health. The attractiveness of bathhouse-based services to some clients was so evident that bathhouses started advertising on their event calendars when testers would be available. Bathhouse owners have found that some clients come to the bathhouse specifically to access sexual health services.
A shift in culture
Providing services in venues where people may not expect them requires open, flexible and dynamic strategies from the nurses providing testing. For instance, some clients may have consumed alcohol or other substances prior to inquiring about testing. Others may not feel prepared to receive certain services or, in the case of POC testing, an HIV test result. Further, STOP nurses are aware that they have entered and are providing services in environments that can be highly sexualized. Nurses use a variety of strategies to function appropriately, effectively and safely within these unique environments. The nurses take a friendly, open approach when potential clients seemed interested in the services they are providing. Maintaining a jovial attitude while setting consistent boundaries by clearly communicating their role allows nurses to be present and professional in a sex-positive atmosphere.
Interactions with patrons can range from answering a few questions informally to describing the services they can provide prior to asking a patron whether they are interested in them. No two clients necessarily receive the same service: nurses engage in a discussion with clients to determine their state of mind and suggest tailored testing options to determine the most appropriate service(s). For instance, if through discussions the nurse and client agree it is not the best time for the client to get tested, the client is referred to other services and/or testing locations. Alternatively, if it is agreed the client wants to take a test but not receive results that day or in the bathhouse/mobile van, a nurse will offer to provide a standard blood-draw HIV test so the client can get results from the nurse at another time and location where they feel more comfortable. Often this second option is particularly appealing to clients when they are informed that the standard blood draw also includes a nucleic acid amplification test (NAAT). This is largely because the window period of the NAAT test is 10-12 days rather than the 12 weeks of the POC antibody test, meaning the NAAT test may reflect more recent high-risk activities.
With both the mobile and bathhouse-based venues, project co-ordinators were aware some community members might disapprove of their presence. Indeed, some people frequenting venues where STOP was providing community-located services said they would not want to access services in that setting and would prefer to attend a clinic. Through client satisfaction surveys and informal conversations with those who did access the services, the STOP Outreach Team nurses generally found reaction to be very positive. Many community members were happy to see the services available and found them convenient. While venue-based sexual health services were not for everyone, those who did use them appreciated their availability and were happy with the quality of services.
Performance results of both the KOTG mobile testing service and bathhouse testing project have shown that each project provides an opportunity for HIV and STI testing in communities of people who may not get tested otherwise.
The bathhouse testing project determined a 3 percent HIV-positivity, significantly above the widely accepted 0.01 percent threshold for cost-effectiveness. Of those patrons who did test positive for HIV, more than 64 percent were 35 years or younger, 27 percent of those diagnosed with HIV were diagnosed when they were already eligible for treatment (at a CD4 count of less than 500), and 18 percent had never been tested for HIV before.
KOTG also reaches an important demographic: evaluations found that 10 percent of people using the service had never been tested for HIV, 18 percent had never been tested for STIs, and 45 percent had not had an HIV test in more than one year.
Nurses have noted, however, that beyond statistics a great deal of their success has been in the day-to-day interactions with patrons of the spaces where they are providing services. Being present, approachable and friendly has enabled them to develop good relationships with the community of people they interact with and helps to normalize the idea of sexual health and HIV/STI testing. STOP Outreach Team nurses have also found that while STIs and HIV may initially bring someone to their clinic, a far greater range of health and psychosocial issues beyond HIV and STIs arise, giving nurses the opportunity to address these health concerns or make referrals to other services. In this way, the nurses are able to provide sexual health services while also incorporating a broader perspective on gay men’s health. If clients require any type of follow-up or post-testing support, nurses make sure to obtain their contact information and make themselves available at their home clinic for further consultations.
The KOTG and bathhouse pilot projects show it is possible to provide comprehensive sexual health services in nontraditional settings. By developing strong relationships, maintaining a passive approach and providing flexible and individualized services, clients who may not otherwise access services are given the opportunity to initiate contact with healthcare providers. Importantly, this initial contact can move far beyond simple provision of STI/HIV screening to include and improve access to on-going services and care. This gives clients the opportunity to address other aspects of their health and well-being that may impact their risk for acquiring HIV or, if they are HIV-positive, to address broader health concerns in order to manage their HIV effectively.
Geoffrey Ford, RN BScN
Nurse Educator, STOP HIV Outreach Team
Vancouver Coastal Health
YouthCO AIDS Society
Toll Free (in Canada): 1-855-YOUTHCO (968 8426)
- Anderson I. Community Consultation Final Report [Internet]. Vancouver, B.C.: Health Initiative for Men; 2011. Available from: http://checkhimout.ca/assets/uploads/files/HIM_Community_Consultation_Report_Final.pdf