Prevention in Focus

Fall 2019 

Task-shifting in HIV testing services

By Amanda Giacomazzo

An estimated 14% of HIV-positive Canadians are unaware of their status.1 People who are undiagnosed cannot benefit from HIV care and treatment and most HIV transmissions originate from people who are undiagnosed or are diagnosed but not in care.2

Changing approaches to testing can potentially reduce the proportion of people who are undiagnosed. One way to increase access to testing is through task-shifting (also known as task-sharing). This entails distributing tasks from highly trained clinical health providers to lay providers (e.g., peers, outreach workers) with less training, or with training in specified tasks.3 Testing technologies such as point-of-care (POC) testing and dried blood spot testing can make it easier for lay providers to bring HIV testing to communities and could increase testing and diagnosis, especially among at-risk populations.

This evidence review outlines findings on task-shifting approaches for HIV testing, focusing on the following topics:

  • the accuracy and quality of HIV testing by lay providers
  • the acceptability of and satisfaction with HIV testing carried out by lay providers
  • the uptake of HIV testing by lay providers

What are the findings of the evidence review?

Most of the evidence related to the use of task-shifting in HIV testing is from low- and middle-income settings; there is less research evidence available from high-income healthcare settings. International guidelines (World Health Organization) and recommendations (International Association for Physicians in AIDS Care) support the use of task-shifting in HIV testing.4,5 Available research evidence demonstrates the following:

  • Lay providers are able to perform testing with accuracy that is comparable to that of laboratory professionals (moderate evidence).
  • People are generally accepting of and satisfied by testing received from lay providers (moderate evidence).
  • There is good uptake, and in some cases higher uptake, of testing provided by lay providers compared with that provided by clinical providers (strong evidence).

Further details of the methodology used for the literature review are available near the end of the article.

Why is testing important?

The concept of the HIV treatment cascade (also known as the continuum of care) is one way to determine how well the system is doing in testing people, engaging and keeping people in care and getting them on successful treatment. Treatment for HIV improves not only health but also quality of life, and maintaining an undetectable viral load plays a key role in the prevention of HIV transmission.6–8 The cascade consists of the successive steps that are needed for a person with HIV to achieve and maintain an undetectable viral load.

Testing is the first step in the HIV treatment cascade. The goal is to make people aware of their status so that they can go on to be linked to clinical care. Since testing identifies people for potential engagement in care and treatment, if we increase testing rates we can increase the likelihood of treatment initiation and viral load suppression.

In Canada, there were an estimated 63,110 HIV-positive people in 2016.1 The estimates of engagement across the treatment cascade are as follows:

  • 86% of people with HIV know their status
  • 81% of people diagnosed with HIV are taking antiretroviral therapy (ART)
  • 91% of people taking ART have an undetectable viral load

On the basis of these data approximately 14% of Canadians with HIV do not know their status. Testing initiatives are needed to attempt to reach this undiagnosed population to realize the health and prevention benefits associated with care and treatment.

What is task-shifting?

The idea of task-shifting has been around for decades. Task-shifting involves distributing tasks from highly trained clinical healthcare providers to lay providers with less training, or training in specified tasks.9 This approach has been adapted for use in many countries.10 Task-shifting has been used not only in HIV testing but also in other areas of the HIV treatment cascade (e.g., treatment), as well as in fields other than HIV.

Lay providers or non-clinical providers (e.g., peers, social workers, outreach workers) are people who have been trained to deliver specific healthcare services (e.g., testing services) but who are not clinicians (e.g., physicians, nurses, pharmacists) with a professional or paraprofessional certification or tertiary degree4 related to healthcare.

Some of the advantages of task-shifting generally include:

  • decentralizing services and bringing services closer to where people are9
  • providing culturally sensitive care that may help to reach people in the lay providers’ community3
  • the ability to address healthcare worker shortages by making use of underutilized resources9
  • potential cost-savings by shifting services from highly trained clinical staff to staff trained for specific tasks4
  • increased opportunities for interactions between workers and clients, which can lead to better adherence, patient follow-up and support9

In the case of HIV testing, task-shifting means using lay providers to perform:

  • pre- and post-test counselling,
  • testing (typically rapid point of care or dried blood spot)
  • linkage to care/prevention, depending on test results

Lay providers have to receive appropriate training to provide these services. In addition, quality assurance mechanisms need to be in place to ensure that lay providers are offering high quality testing services.3

What are the current guideline recommendations for HIV testing by lay providers?

The 2015 guidelines on HIV testing services published by the World Health Organization (WHO) state “lay providers who are trained and supervised to use rapid diagnostic tests (RDTs) can independently conduct safe and effective HIV testing services.” This is classified as a strong recommendation based on sources with moderate-quality evidence largely from low- and middle-income countries.4

To optimize the HIV care environment, the International Association of Providers of AIDS Care also recommends the use of lay health workers to provide pre-test education and testing when they are provided with the proper education and oversight and guided by national policies.5

Where is HIV testing by lay providers used?

An international review of policies for lay provider testing found that 42% of the 50 countries surveyed permit lay providers to perform HIV testing with finger-stick blood tests and 56% permit lay providers to administer pre-and post-test counselling. Fewer countries reported allowing lay providers to perform HIV testing using oral fluids (18%). The review recommends that countries consider using lay providers to increase HIV testing, especially in circumstances where a person may not visit a traditional health clinic.11 Of note, Canada’s 2012 HIV Testing and Screening Guide does not mention the use of lay providers for HIV testing.12

There are examples of HIV testing by lay providers in Canada (e.g., Anonymous HIV Testing Program in London, Ont., and Peer HIV Testing in Vancouver, BC), but lay providers may not be involved in testing in all provinces and territories. CATIE hosted a national Deliberative Dialogue in 2016 that included 50 leading experts in HIV testing and linkage programming (e.g., people living with HIV, policy-makers, health planners in clinical and public health and service providers) to discuss approaches to effective testing and linkage to care. One of the priority directions identified was to enhance the role of peers and other non-regulated and allied health professionals as testers. An action plan for 2015–2020 on POC testing in Canada that was developed as part of another Canadian project also suggested training allied health professionals and lay providers (e.g., peers) to provide HIV POC testing to increase the number of people involved in testing. The report setting out the action plan also identified a need to have clear standards related to HIV POC testing.13

Considerations for testing by lay providers

The WHO sets out the following considerations for testing by lay providers:3

  • Lay providers should be well trained and connected to the people whom they serve.
  • Training, mentoring and ongoing support are required for lay providers who offer testing and pre- and post-test counselling.
  • Quality assurance measures should be put in place to ensure lay providers have adequate training on how to conduct tests and complete pre- and post-test procedures.
  • Adequate remuneration for lay providers should be provided.
  • Policy and regulatory changes are needed to establish the role of trained lay providers (e.g., salary information, regulatory procedures).

In the WHO’s guidelines, all HIV testing, including testing by lay providers, should adhere to the 5 Cs:4

  • informed consent
  • maintenance of confidentiality
  • pre- and post-test counselling
  • correct diagnosis
  • connection or linkage to prevention or treatment and care

The WHO recommends that the training given to lay providers include confidentiality training, training related to the needs of key populations, including local support and prevention services, and training related to HIV testing laws (e.g., age of testing).4

Accuracy and quality of testing by lay providers

One systematic review considered the accuracy and quality of HIV testing for HIV screening.10 A randomized controlled trial and two observational studies (moderate evidence) met the search criteria for inclusion in a 2017 systematic review. These studies were conducted in South Africa, Malawi and Cambodia. No additional single studies that met the search criteria were identified.

The systematic review10 found that the quality of tests performed by lay providers was comparable to that of tests performed by trained healthcare professionals:

  • In South Africa, a randomized controlled trial included the use of home-based HIV testing delivered by lay providers who were community health workers.  Lay providers completed a 10-day training where they learned how to provide HIV testing services,  including how to conduct a finger-prick HIV test and dried blood spot testing, and they shadowed counsellors for three months. Only 0.06% of almost 4,000 tests had discordant results in which the lay provider found a positive result and the lab found a negative result. The sensitivity of the tests performed was 98.0% and the specificity was 99.6%.14
  • A study from rural Malawi considered the quality of home-based rapid HIV testing delivered by lay providers trained and certified to perform HIV counselling, whole-blood testing and finger-prick specimen testing. Only four of 2,911 tests (0.13%) had discordant results in which the lay provider found a different result than the lab. Results showed a 99.6% sensitivity and 100% specificity.15
  • In Cambodia, a study compared the results of HIV testing completed by lay providers and laboratory technicians. Lay providers were trained HIV testing counsellors and received a half-day training on collecting finger-stick whole-blood samples. Of the 563 samples, 100% were concordant between lay providers and laboratory testers (four errors were observed; however, these were determined to be human errors made when the lab reports were written rather than errors made by the counsellors).16

Acceptability of and satisfaction with testing by lay providers

Six studies (two of which were included in a systematic review) considered the acceptability of and satisfaction with HIV testing conducted by lay providers. One of these studies was a randomized controlled trial and the other five were observational studies (moderate evidence). Participants expressed satisfaction with lay provider testing, although there was a lack of consistency in the indicators used across the studies.  

From a 2017 systematic review:10

  • A randomized controlled trial from Boston, Massachusetts (USHER study) compared the provision of HIV testing services by lay providers (i.e., HIV counsellors) and healthcare providers in an emergency department. In the lay provider arm, trained HIV counsellors provided the testing services (e.g., test consent, test results delivery, referral for confirmatory testing). In the healthcare provider arm, emergency service assistants performed the tests and physicians gave the results and follow-up information. A high level of satisfaction was found overall, at 91.5%, but the level of satisfaction was slightly higher in the lay provider arm. Multivariate results indicated that participants tested by healthcare providers were more likely to be less than optimally satisfied (i.e., very dissatisfied, somewhat dissatisfied or somewhat satisfied) than those tested by lay providers. Patients in both arms reported optimal satisfaction with the tester’s ability to answer questions (100%).17
  • An observational study from Botswana conducted exit interviews with clients who had received HIV testing from lay providers. Ninety-eight percent of clients reported being satisfied with the HIV testing services they received.18

PRONTO! is a community-based and peer-led rapid POC testing program for gay, bisexual and other men who have sex with men (MSM) in Australia. PRONTO! offers free HIV testing during a 30-minute appointment. Appointments can be booked online, by phone or on-site. Text message reminders are used to remind participants of their appointment. The program is almost entirely staffed by men who self-identify as gay. Staff received training on how to conduct rapid POC testing and on pre- and post-test counselling.19–21 Results of two observational studies conducted in 2013–2014 indicate the following:

  • Two-thirds of participants reported that they preferred testing with peers versus doctors or nurses. They said that peers were more relatable and that they better understood the concerns of participants.20,21
  • Ninety percent of participants agreed or strongly agreed that peers were competent in performing the tests.21
  • Participants reported that the peer model reduced anxiety associated with testing and increased their comfort level with testing.20,21

The RAPID Australia program is a POC testing program that uses a mobile van at community “beat” (cruising) locations and is staffed by MSM peer testers. The program originally started as a proof-of-concept project. Clients engage with peer testers in a safe, non-judgmental environment to discuss prevention (e.g., pre-exposure prophylaxis; PrEP) and testing. The peers who provide testing receive training as part of the project.22,23 Results from an observational study (2016–2017) indicate that 90% of repeat testers felt more comfortable receiving testing at RAPID than receiving conventional testing and 82% reported it was much less stressful.22 An additional observational study found that 78% of participants agreed that the mobile van was an acceptable method of POC testing and 78% said that they would be happy to refer a friend to the facility.23

Uptake of lay provider testing

Evidence on the uptake of lay provider testing comes from a systematic review (which included one randomized controlled trial and one observational study), a systematic review and meta-analysis (which included one randomized controlled trial, two quasi-experimental studies and four observational studies) and an additional four observational studies (strong evidence). There is generally high uptake when testing by lay providers is offered and in many cases, testing by lay providers is able to reach first-time testers.

From a 2017 systematic review:10

  • A randomized controlled trial from Boston, Massachusetts (USHER study) compared the provision of HIV testing services by lay providers and healthcare providers in an emergency department. In the lay provider arm, trained HIV counsellors provided the services (e.g., test consent, test results delivery, referral for confirmatory testing). In the healthcare provider arm, emergency service assistants performed the tests and physicians gave the results and follow-up information. Lay providers and emergency service assistants received a one-day training. Uptake in the lay provider arm was significantly higher (57%) than in the healthcare provider arm (27%).  The study authors stated that this difference may  have been due to competing priorities in the healthcare provider arm.24
  • An observational study examined the uptake of lay provider testing before and after program implementation in Malawi. All lay providers received 13 weeks of training (10 weeks of health surveillance assistant training and three weeks of HIV testing services counsellor training). Testing increased by 400% after implementation (from 2003 to 2009) from 1,300 to 6,500 tests per month. No data was provided on the positivity rate.25

A 2017 systematic review and meta-analysis investigated the effectiveness of peer-based testing among MSM. It included seven studies: one randomized controlled trial, two quasi-experimental studies and four observational studies. Three of the studies were from the United States, two from the United Kingdom, two from Asia and one from Africa. In this meta-analysis, HIV testing rates were higher in the peer arm than in the control arm (odds ratio 2.0).26

In Ottawa, Canada, a model for community-based peer-administered HIV POC testing for people who use drugs was developed as part of the observational PROUD study, which took place in 2013. Study interviewers (11 peers, 15 medical students and three community allies) received POC test training that included information related to confidentiality, HIV, infection control and quality assurance, performing the POC test and interpreting the results, and pre- and post-test counselling. Interviewers offered participants POC testing at the end of the study interviews and conducted POC testing for those who accepted. A public health nurse provided support and drew blood for confirmatory testing if a test was reactive or had an indeterminate result. Of the 593 people who were offered a POC test, 83% consented to testing and 16% of those participants had never been tested for HIV.27

PRONTO! is a community-based and peer-led rapid POC testing program for MSM in Australia. PRONTO! offers free HIV testing during a 30-minute appointment. Appointments can be booked online, by phone or on-site. Text message reminders are used to remind participants of their appointment. Men who self-identify as gay staff the program almost entirely. Staff received training on how to conduct rapid POC testing and on pre- and post-test counselling.19–21 Results of an observational study (2013–2014) indicate the following:19

  • In the first 12 months of the program 1,616 tests were performed on 1,320 individuals.
  • Sixty-eight percent of men who were tested reported behaviours that would classify them as being at high risk for HIV.
  • Twenty-three percent of sexually active men who were tested in the first 12 months of the program returned for testing in the subsequent six months.

The RAPID Australia program is a POC testing program that uses a mobile van at community “beat” (cruising) locations and is staffed by MSM peer testers. The program originally started as a proof-of-concept project. Clients engage with peer testers in a safe, non-judgmental environment to discuss prevention (e.g., PrEP) and testing. The peers who provide testing receive training as part of the project. An observational study on the program found that in 2014–2015, 1,199 people attended RAPID to receive a free HIV test and that 20% were first-time testers.22

Check Point Portugal offered free, anonymous and confidential rapid HIV and syphilis testing to MSM using a team of eight trained peer testers. Peers were supported and supervised by health professionals and they worked as a team. When a person tested positive a referral protocol was initiated that connected them to a local hospital where they received an appointment within two weeks of diagnosis. In an observational study, over 5,156 tests were performed between 2011 and 2014.28,29

What does this mean for service providers?

Guidance from the WHO and the International Advisory Panel on HIV Care Continuum Optimization recommends using lay providers in rapid POC testing for HIV. Service providers in Canada may want to consider using lay providers to increase access to testing in areas where populations do not make regular visits to clinical settings and to assist with bringing testing to where people are. It is important to consider the population that a lay provider testing program is trying to reach and to continually monitor whether these approaches to testing are reaching previously undiagnosed populations.

The ability to use lay providers for testing varies across Canada, and service providers should look for guidance in their specific region and from within their organization. Lay provider testing may require the support of a medical directive for non-clinical providers to perform testing services and the need for, and development of, a medical directive may be determined at an organizational level.

Lay providers should have adequate training and support to perform the tasks associated with testing. This includes the use of on-site supervisors and someone trained in laboratory procedures. It is important that lay providers achieve and maintain competency in testing procedures, as well as medical ethics, confidentiality and counselling, to ensure the quality of testing. A quality control system, as well as quality standards and procedures, should be used with all HIV testing to ensure testing accuracy and quality.3

Methodology

The purpose of this literature review is to summarize research information on the use of task-shifting to lay providers in HIV testing. The key search terms used were HIV, testing, administer test, peer, community advocate, lay provider and paraprofessional (Embase search terms). Searches were limited to research literature published between January 2015 and March 2019 and were focused on Canadian or similar health systems (e.g., Australia, United Kingdom, Portugal). Articles were identified using PubMed and Embase as well as through the review of reference lists of relevant articles. Articles related to the use of task-shifting in low- and middle- income countries were excluded from the review, except where they were included in review articles. Research literature from low- and middle-income countries, as well as research literature before 2015, was largely captured in the systematic review articles included here.10

Strength of evidence

The available scientific literature was reviewed to determine the linkage-to-care outcomes associated with various programmatic approaches, as well as barriers and facilitators associated with linkage to care. Although the evidence rating was flexible (to a certain degree), ratings were based on the following criteria:

  1. Strong evidence: At least one systematic review or a large body of randomized controlled trials and quasi-experimental studies (with the support of observational research) supports the ability of the intervention to affect the outcome.
  2. Moderate evidence: A limited number of randomized controlled trials and/or quasi-experimental studies (with the support of observational research) support the ability of the intervention to affect the outcome.
  3. Limited evidence: Observational research supports the ability of the intervention to affect the outcome.
  4. No evidence: No published research exists to support the ability of the intervention to affect the outcome.

The strength of the evidence is based on the quantity and quality of the evidence and not the size of the outcome.

 

References

  1. Government of Canada. Summary: Estimates of HIV incidence, prevalence and Canada’s progress on meeting the 90-90-90 HIV targets, 2016. 2018. Available from: https://www.canada.ca/en/public-health/services/publications/diseases-conditions/summary-estimates-hiv-incidence-prevalence-canadas-progress-90-90-90.html
  2. Li Z, Purcell DW, Sanson SL et al. Vital signs: HIV transmissions along the continuum of care – United States, 2016. MMWR Morbidity and Mortality Weekly Report. 2019; 68(11):267-72.
  3. World Health Organization. HIV Testing: WHO Recommends HIV Testing by Lay Providers. Policy Brief. Geneva: World Health Organization; 2015. Available from: https://www.who.int/hiv/pub/toolkits/policy-hiv-testing-by-lay-provider/en/
  4. World Health Organization. Consolidated Guidelines on HIV Testing Services: 5Cs: Consent, Confidentiality, Counselling, Correct Results and Connection. Geneva: World Health Organization; 2015. Available from: https://www.who.int/hiv/pub/guidelines/hiv-testing-services/en/
  5. International Advisory Panel on HIV Care Continuum Optimization. IAPAC guidelines for optimizing the HIV care continuum for adults and adolescents. Journal of the International Association of Providers of AIDS Care. 2015;14(Supplement 1):S3-34.
  6. Rodger AJ, Cambiano V, Bruun T et al. Risk of HIV transmission through condomless sex in serodifferent gay couples with the HIV-positive partner taking suppressive antiretroviral therapy (PARTNER): final results of a multicentre, prospective, observational study. The Lancet. 2019;393(10189):P2428-38.
  7. Cohen MS, Chen YQ, McCauley M et al. Antiretroviral therapy for the prevention of HIV-1 transmission. New England Journal of Medicine. 2016;375:830-9.
  8. INSIGHT START Study Group, Lundgren JD, Babiker AG, Gordin F et al. Initiation of antiretroviral therapy in early asymptomatic HIV infection. New England Journal of Medicine. 2015;Aug 27;373(9):795-807.
  9. World Health Organization. Task Shifting: Rational Redistribution of Tasks among Health Workforce Teams: Global Recommendations and Guidelines. Geneva: World Health Organization; 2008. Available from: https://www.who.int/workforcealliance/knowledge/resources/taskshifting_guidelines/en/
  10. Kennedy CE, Yeh PT, Johnson C et al. Should trained lay providers perform HIV testing? A systematic review to inform World Health Organization guidelines. AIDS Care. 2017;29(12):1473-9.
  11. Flynn DE, Johnson C, Sands A et al. Can trained lay providers perform HIV testing services? A review of national HIV testing policies. BMC Research Notes. 2017;10(20).
  12. Public Health Agency of Canada. Human Immunodeficiency Virus: HIV Screening and Testing Guide. Ottawa: Public Health Agency of Canada; 2012. Available from: https://www.canada.ca/en/public-health/services/hiv-aids/hiv-screening-testing-guide.html
  13. Gahagan J, Condran B, Hajizadeh M. HIV Point-of-Care Testing (POCT) in Canada: Action Plan 2015–2020. 2015. Halifax, NS: Dalhousie University; 2015. Available from: https://cdn.dal.ca/content/dam/dalhousie/pdf/Diff/gahps/HIV%20pt%20of%20care%20testing%20eng%20revised.pdf
  14. Jackson D, Naikl R, Tabana H et al. 2013 as cited in Kennedy CE, Yeh PT, Johnson C et al. Should trained lay providers perform HIV testing? A systematic review to inform World Health Organization guidelines. AIDS Care. 2017;29(12):1473-9.
  15. Molesworth AM, Ndhlova R, Banda E et al. 2010 as cited in Kennedy CE, Yeh PT, Johnson C et al. Should trained lay providers perform HIV testing? A systematic review to inform World Health Organization guidelines. AIDS Care. 2017;29(12):1473-9.
  16. Kanal K, Chou TL, Sovann L et al. 2005 as cited in Kennedy CE, Yeh PT, Johnson C et al. Should trained lay providers perform HIV testing? A systematic review to inform World Health Organization guidelines. AIDS Care. 2017;29(12):1473-9.
  17. Donnell-Fink JA, Reichmann WM, Arbelaez C et al. 2011 as cited in Kennedy CE, Yeh PT, Johnson C et al. Should trained lay providers perform HIV testing? A systematic review to inform World Health Organization guidelines. AIDS Care. 2017;29(12):1473-9.
  18. Ledikwe JH, Kejelepula M, Maupo K et al. 2013 as cited in Kennedy CE, Yeh PT, Johnson C et al. Should trained lay providers perform HIV testing? A systematic review to inform World Health Organization guidelines. AIDS Care. 2017;29(12):1473-9.
  19. Ryan KE, Wilkinson AL, Leitinger D et al. Characteristics of gay, bisexual and other men who have sex with men testing and retesting at Australia’s first shop-front rapid point-of-care HIV testing service. Sexual Health. 2016;13:560-7.
  20. Ryan KE, Pedrana A, Leitinger D et al. Trial and error: evaluating and redefining a community model of HIV testing in Australia. BMC Health Services Research. 2017;17(1):692.
  21. Leitinger D, Ryan KE, Brown G et al. Acceptability and HIV prevention benefits of a peer-based model of rapid point of care HIV testing for Australian gay, bisexual and other men who have sex with men. AIDS Behaviour. 2018;22:178-89.
  22. Mutch AJ, Lui C, Dean J et al. Increasing HIV testing among hard-to-reach groups: examination of RAPID, a community-based testing services in Queensland, Australia. BMC Health Services Research. 2017;17(1):310.
  23. Mullens AB, Duyker J, Brownlow C et al. Point-of-care testing (POCT) for HIV/STI targeting MSM in regional Australia at community ‘beat’ locations. BMC Health Services Research. 2019;19(1):93.
  24. Walensky RP, Reichmann WM, Arbelaez C et al. 2011 as cited in Kennedy CE, Yeh PT, Johnson C et al. Should trained lay providers perform HIV testing? A systematic review to inform World Health Organization guidelines. AIDS Care. 2017;29(12):1473-9.
  25. Bemelmans M, Van Den Akker T, Ford N et al. 2010 as cited in Kennedy CE, Yeh PT, Johnson C et al. Should trained lay providers perform HIV testing? A systematic review to inform World Health Organization guidelines. AIDS Care. 2017;29(12):1473-9.
  26. Shangani S, Excudero D, Kirwa K et al. Effectiveness of peer-led interventions to increase HIV testing among men who have sex with men: a systematic review and meta-analysis. AIDS Care. 2017;29(8):1003-13.
  27. Lazarus L, Patel S, Leblanc S et al. Uptake of community-based peer administered HIV point-of-care testing: findings from the PROUD study. PLoS ONE. 2016;11(12):e0166942.
  28. Peer-delivered HIV/AIDS community testing and prevention services in Lisbon, Portugal. Case Profile. N.d. Available from: https://www.integratedcare4people.org/media/files/CaseProfilePortugal.pdf
  29. Meireles P, Lucas R, Martins A et al. The Lisbon Cohort of men who have sex with men. BMJ Open. 2015;5(5):e007220.

About the author(s)

Amanda Giacomazzo is CATIE’s knowledge specialist, treatment and prevention programming. She holds a Master’s degree in health science with specialised training in health services and policy research and has previously worked in knowledge translation and public health at the provincial level.