Prevention in Focus

Spring 2014 

Shifting the paradigm: The history of the Vancouver STOP HIV/AIDS Project

By Christine Johnston

The Seek and Treat for Optimal Prevention of HIV/ AIDS (STOP) Project was a three-year pilot to March 31, 2013, funded by the Ministry of Health. The aim of the STOP Project was to expand HIV testing, treat­ment, care and support to reduce HIV transmission and improve the quality of life of people living with HIV in British Columbia (B.C.). Funding was provided to Vancouver Coastal Health (VCH), Northern Health, Provincial Health Services Authority, Providence Health Care (PHC) and the B.C. Centre for Excellence in HIV/AIDS.

To accomplish the goals of the STOP Project within the city of Vancouver, Vancouver Coastal Health and Providence Health Care came together to form the Vancouver STOP HIV/AIDS Project (Vancouver STOP Project). Through this partnership, the Vancouver STOP Project approached the theoretical underpin­ning of STOP, the theory of treatment as prevention, as a framework through which to address all aspects of the HIV continuum of care. In doing so, they suc­cessfully facilitated transformation across the entire system of care in the city – across HIV testing, diag­nosis and case finding, linkage to care for new and existing clients, HIV treatment and retention, and HIV support.

The Vancouver STOP Project had the following aims, which were guided by the STOP Project goals: 1) reduce HIV incidence; 2) improve early detection of HIV; 3) ensure timely access to high-quality and safe HIV/AIDS care and treatment; 4) improve the client experience in every step of their HIV/AIDS journey; and 5) demonstrate system and cost optimization.

The Vancouver STOP Project met these aims and ultimately transformed the HIV system of care in the city through a variety of initiatives and activities, including community engagement with people living with HIV, evidence review, consultations with service and healthcare providers, the development of popu­lation-specific reports, constant assessment of the current state of the HIV system of care, policy change, and the funding, monitoring and evaluation of over 40 pilot activities.

Vancouver STOP Project activities: quick wins, pilot projects and changes to existing practice and policy

Using community stakeholder consultation, internal dialogue and visioning, and evidence review, the Vancouver STOP Project identified, implemented and tested activities that would achieve STOP goals from early 2010 to March 31, 2013.

The central strategy of the Vancouver STOP Project as they implemented activities to meet the goals of STOP was to build on the existing infrastructure of ser­vices in Vancouver rather than develop entirely new organizations. To achieve their goals, the Vancouver STOP Project set three priorities: first, to expand the reach and capacity of effective programs in the city; second, to implement new ways of offering services in each step of the client journey; and third, to enhance linkage across the system of care. Some activities were relatively easy to implement and others required significant long-term planning and practice change.

Although all of the Vancouver STOP Project’s activities are often referred to as “pilots,” in practice the project implemented three different types of activities across the client journey: quick wins, pilot projects and chan­ges to existing practice and policy.

The two partner organizations in the Vancouver STOP Project funded activities within their own programs and clinics and collaborated with other community organizations to implement projects on behalf of the Vancouver STOP Project.

Activities related to HIV testing and diagnosis

In 2010, during the time when the Vancouver STOP Project was investigating possible activities and pilots, evidence suggested that Vancouver’s risk-based test­ing model was not reaching everyone who needed an HIV test – approximately 25% of people who were living with HIV still did not know their status, despite extensive risk-based testing opportunities. Among those who were diagnosed, 60% were diagnosed after they should have already been on treatment. Nearly a fifth of patients were diagnosed very late in the course of their illness.

The Vancouver STOP Project’s leadership believed that, to expand HIV testing options and increase diagnoses, the model for testing needed to be funda­mentally shifted. The healthcare system, through its clinical services, could be used to ensure that most people who were infected with HIV had the oppor­tunity for a diagnosis. The Vancouver STOP Project hypothesized that the way to mobilize this system and encourage people to be tested for HIV was to normalize HIV testing. This normalization could be accomplished by offering HIV testing at every oppor­tunity to all patients engaging with the healthcare system who had ever had sex and who had not been tested in the last year – something that would repre­sent a fundamental shift in the HIV testing paradigm in the city.

This shift was represented by a refocusing of HIV test­ing from a singular strategy of risk-based HIV testing to one that combined a routine offer of HIV testing approach with risk-based testing. Specifically, a three-pronged, integrated strategy was taken to expand HIV testing across Vancouver: the routine offer of HIV test­ing in family practice, the routine offer of HIV testing in acute care, and targeted HIV testing in high-preva­lence populations (including enhanced testing in settings already offering HIV testing and expansion of testing to new venues).

To implement the routine offer of HIV testing, the Vancouver STOP Project sought buy-in from clinical and operational leadership in multiple settings, as well as from the College of Physicians and Surgeons of British Columbia, through ongoing and inten­sive engagement activities; supported changes to pre- and post-test counselling policy; and offered extensive support to physicians offering the test.

To expand HIV testing in targeted (high prevalence) settings, a small team of nurse educators came together to support several services and settings that were identified as locations where increased access to HIV testing would benefit clients.

Activities related to linkage, engagement and retention in treatment, care and support

The Vancouver STOP Project sought to improve the client journey across the full continuum of HIV services. One of the most significant aspects of this work was the effort to, and ultimately the success in, enhancing linkage, engagement and retention in all components of this continuum.

Accessing and remaining in care can be a challenge for people who are newly diagnosed and for people living with HIV or AIDS who have known their status for some time. Providing support to people living with HIV or AIDS to ensure their engagement and retention was a significant component of the Vancouver STOP Project’s goal to improve the client journey.

To reduce the number of people lost to care after their diagnosis and to increase the number of people engaged in care, the Vancouver STOP Project developed a strong and reliable system for fol­low-up and engagement in care, which was made up of multiple discrete but interconnected pilots. Part of the success of the Vancouver STOP Project is directly attributable to these new or expanded ser­vices in Vancouver and the fact that these services, which serve a diversity of clients, were implemented almost simultaneously.

These activities included the enhancement of linkage mechanisms from HIV testing sites; the creation of new navigation and linkage services, such as the Peer Navigation Services Program and the STOP Outreach Team, which specialize in engagement, linkage and retention in care; and the enhancement of existing services that aim to support some of the most vulner­able people living with HIV in Vancouver, such as the Towards Aboriginal Health and Healing Program, the Maximally Assisted Therapy Program and supportive housing services.

Enhanced public health follow-up services

During the Vancouver STOP Project pilot, public health-follow up was established as a critical compon­ent of any HIV diagnosis and significant shifts took place in how this follow-up is carried out.

In Vancouver, public health follow-up is the primary responsibility of VCH Communicable Disease Control (VCH CDC). This service includes support to clin­icians and clients for diagnosis, partner notification, disclosure and linkage to care. It is staffed by a team of public health nurses and directed by the medical health officer for communicable diseases.

Before the initiation of the Vancouver STOP Project, public health follow-up for people diagnosed with HIV included a relatively passive process for partner notification and some case management of clients in need. The role of public health in the care of people diagnosed with HIV was not very well known to healthcare providers in the city, and the services that VCH CDC offered were not fully integrated with the HIV primary care of those recently diagnosed, nor were these services maximized to benefit clients and their partners.

The Vancouver STOP Project provided an oppor­tunity to expand and improve public health partner notification and integrate it more effectively into HIV treatment, care and support services. Working with the medical health officer for communicable diseases, the Vancouver STOP Project focused on improving the measurement of outcomes of partner notification to determine where notification was occurring optimally and where it needed to improve; engaging and sup­porting healthcare providers; and engaging people living with HIV to actively link them to care.

Perhaps the single most important change to public health follow-up was the shift from a passive to an active approach. Today, as a result of the Vancouver STOP Project, nurses from VCH CDC actively follow up with partners who have been notified to ensure they get tested, receive their results and, if found to be positive, receive the care and support that VCH CDC can provide.

Developing and implementing a monitoring and evaluation framework

The Vancouver STOP Project activities were mon­itored and evaluated at the provincial level, the local health service delivery area level and at the pilot project level.

Provincial-level monitoring and evaluation, using 29 indicators, were conducted by the B.C. Centre for Excellence in HIV/AIDS using provincial testing data from the B.C. Centre for Disease Control and provincial treatment data from the provincial drug treatment program at the B.C. Centre for Excellence in HIV/AIDS.

Monitoring and evaluation at the level of the local health service delivery area and pilot project took place using a two-pronged approach. The first prong focused on the health service delivery area level. Through a partnership with the Public Health Surveillance Unit (PHSU), which is a part of VCH, the Vancouver STOP Project Team developed and formalized a population monitoring and program evaluation framework. This framework informed the overall monitoring outputs and outcomes of STOP at a population level within Vancouver and included over 50 indicators. These activities were led by PHSU, in close consultation with the Vancouver STOP Project. Although some of the data required to assess the population-level success of the Vancouver STOP Project were accessible within VCH, most of the data were obtained by establishing data linkages with a variety of groups, including the B.C. Centre for Disease Control and the B.C. Centre for Excellence in HIV/AIDS.

The second prong comprised analyses at the level of individual pilot projects funded by VCH and or PHC; these analyses were conducted by staff of the Vancouver STOP Project. This prong included developing pilot project logic models and assessing short- and long-term pilot outcomes, using qualitative and quantitative data collected in partnership with pilot project partners.

The monitoring and evaluation of the Vancouver STOP Project was designed to allow the project lead­ers, other leaders and relevant committees to make informed decisions regarding project steering, imple­mentation and resource allocation.

Planning for the future state of HIV services

In addition to implementing system change across the continuum of care, the Vancouver STOP Project also carried out intensive “future state” planning activ­ities. The purpose of these activities was to support a redesign of the current system of care and services to create an ideal state for people living with and at risk for HIV.

Knowledge transfer and exchange

The Vancouver STOP Project prioritized the documen­tation of key pilot activities and outcomes and the overall implementation of the project through PHC and VCH. Their goal in documenting the project was to ensure that the lessons learned from this ground-­breaking project are not lost and successes can be sustained.

In April 2012, CATIE, as Canada’s HIV and hepatitis C knowledge exchange broker, was engaged to support the Vancouver STOP Project’s knowledge exchange activities. This included the development of a knowledge exchange plan, the publication of 13 case studies in CATIE’s online Programming Connection, the publication of a report on the over­all implementation of the Vancouver STOP Project, and the recording of the Ministry of Health’s STOP Project Provincial Expansion Knowledge Exchange Kickoff Event in January 2013. For more detailed information on specific pilot activities, please see CATIE’s Programming Connection case studies.

Conclusions drawn from the experience of the Vancouver STOP Project

In implementing treatment as prevention in the real world, the Vancouver STOP Project was not only suc­cessful in meeting the overall aims of the STOP Project pilot but it also generated much information about the ideal landscape of HIV services in Vancouver. Lessons were learned about how to take the first steps toward changing a system of care and about what must be in place to ensure success. The activities of the Vancouver STOP Project also had unintended consequences, which should be considered by others attempting to change their own system of care to bet­ter address the needs of people living with and at risk for HIV. All of the lessons learned and key conclusions drawn from the experience of the Vancouver STOP Project can be found in the full report: Shifting the Paradigm: the History of the Vancouver STOP Project.

About the author(s)

Christine Johnston is the Manager of Community Prevention Programs at CATIE. She holds a Masters degree in Anthropology and International Relations. Before joining CATIE, Christie worked on a number of community-based research and knowledge exchange projects at the Ontario HIV Treatment Network (OHTN), AIDS Committee of Toronto (ACT) and abroad, and acted as Volunteer Program Coordinator for the AIDS 2006 Local Host Secretariat.

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