Bringing STBBI testing to people who use drugs
Nine Circles Community Health Centre (Nine Circles) has integrated a registered nurse (RN) within a harm reduction supply distribution room for one hour per day, four days a week. A health educator, known as a community facilitator, distributes requested drug supplies and asks clients if they are interested in testing for sexually transmitted and blood-borne infections (STBBIs). If clients are interested, the community facilitator refers them directly to an RN if one is present or notifies clients of testing hours. The goal of the initiative is to increase testing for STBBIs including HIV, hepatitis C and syphilis, and gonorrhea for people who inject drugs. Testing options include blood and urine samples, rectal and throat swabs and point-of-care tests (i.e., rapid HIV tests). A secondary goal of the program is to connect clients to the primary care services on site if they have no current provider. Nine Circles delivers comprehensive primary care, social support, education and prevention services creating healthier communities for Manitobans.
Why was the program developed?
Nine Circles was part of a project that explored STBBI testing challenges and opportunities in Winnipeg through the Manitoba HIV Collective Impact Network, which is working to transform the landscape of HIV in Manitoba through stigma reduction and prevention, as well as testing and linkage initiatives. The project involved reviewing who is currently using testing services, developing opportunities for collaboration to connect with hard-to-reach populations, and sharing tools and best practices related to completing sexual health assessments. The work also included a client survey, a forum for educators and clinicians who do HIV/STBBI testing, and a final report, which outlined results of this work and made recommendations on next steps.
On the basis of the recommendations of the report, Nine Circles recognized that clients who were accessing their low-threshold harm reduction supply distribution services were not accessing the other health services offered at the community health centre (e.g., primary care, STBBI testing). In response to this identified need, an RN from the health clinic was brought into the harm reduction program four days a week for one hour each day to provide testing and primary care referrals to people who use drugs. This program started on July 3, 2018.
Tammy Reimer, Director of Allied Care and Health Promotion at Nine Circles, explains:
“…we were still trying to find ways for those who were not accessing care to come through our door and fit into our system (e.g., make an appointment and return, wait at the drop in). The challenge was to think about what it would look like for us to walk out the door to the client. What we needed to do was utilize the space/program where staff had already developed a level of trust and to build on this by offering testing and subsequently primary care.”
How does it work?
When a client visits the harm reduction program at Nine Circles they can request drug use supplies from the community facilitator, who is a member of the health education team. The community facilitator, through their interactions with the client, asks if the client is interested in STBBI testing. If this occurs Monday, Tuesday, Thursday or Friday between 1:00 and 2:00 pm the community facilitator directly connects the client with an RN if the client wishes to be tested. If this happens outside these hours the client is encouraged to return during testing hours for their test.
An RN initially connects with a client in the supply distribution room and testing is completed in an exam room, office space or the supply distribution room, although testing in the supply distribution room is less frequent. The RN shares testing options with clients that include point-of-care tests, swabs, and urine and blood sampling, and clients identify which STBBI testing they are interested in (e.g., chlamydia, gonorrhea, syphilis, HIV, hepatitis C), as well as the type of tests that they would like. The client provides verbal consent and the RN proceeds to collect the specimens for analysis. The role of the RN also includes getting to know clients and building trust.
Clients receive results of point-of-care tests on the spot. For other types of testing, the client can provide a contact number or email and the RN will follow up with them in one or two weeks if any of the test results are positive. If the client does not have contact information, they are encouraged to check back with the community facilitator in one or two weeks for test results or make an appointment at the health centre.
In terms of linking clients to primary care, the nurse asks clients about whether they have a primary care provider, and asks those who do not whether they would like to be connected to one. Depending on where clients are at, they may be interested in being linked to a provider or may prefer to see the sexually transmitted infection (STI) nurse if treatment for an STI is required. Under a directive (allows specific procedures to be delegated to and conducted by another trained health professional), nurses can currently provide treatment for STIs at Nine Circles and in the future they will be able to so independently after completing an advanced prescriber course (probably by 2020).
The RNs have documentation requirements related to this program, which requires up to approximately 30 additional minutes/day. The RN creates a chart for the client (with their permission) and collects data such as whether the client is a first-time tester and the test results and then collects information about any repeat testing that the client receives. The initiative does not require any additional funds to implement.
What has the program accomplished?
An evaluation of the first 12 weeks of the program indicates that a nurse was available in the supply distribution room for a total of 44 hours (i.e., one hour per day for four days a week). In this time, 17 people were open to connecting with a nurse about testing, with 15 of those individuals consenting to testing. Out of the 15 clients who consented to testing:
- 40% (six) were first-time testers (i.e., a person who has not previously been tested for an STBBI)
- 40% (six) tested positive for one or more STBBIs (three people had multiple infections)
- 80% (12) consented to HIV, hepatitis C and syphilis testing
- 33% (five) opted for point-of-care testing for HIV
- 33% (five) completed follow-up by either returning for a booked appointment or following-up with their primary care provider, with four people agreeing to receive a referral to a primary health care provider at Nine Circles
- There were no reactive tests for HIV or hepatitis C
What are the challenges and lessons learned?
The program brings STBBI testing to clients in a low-barrier setting where trust can be established between staff and service users. However, it can be challenging to connect clients to follow-up and treatment services after they receive an STBBI diagnosis, as some clients follow through and others do not.
This program is still in its early stages and currently the nurse is only in the supply distribution room for one hour per day, so it can be difficult to reconnect with clients because of the nurse’s limited availability. As the program continues to operate and learning continues, changes can be made to the approaches used.
The best advice from Kim Witges, Clinical Director at Nine Circles:
“Engage your staff and let them take the lead on what needs to happen; it may fail or succeed, but let it unfold. Be willing to not have all of the answers prior to starting, but be keen to figure it out along the way.”
Kim Witges, Clinical Director
Nine Circles Community Health Centre