Testing Companions

Testing Companions

North Carolina, United States
2016

A novel rapid POC HIV testing program for people accompanying HIV-positive clients to their appointments effective at diagnosing new HIV infections

Since 2007, the University of North Carolina (UNC) Infectious Diseases Clinic has offered free rapid point-of-care (POC) HIV testing to anyone accompanying an HIV-positive client to their HIV clinic appointment. An evaluation of this testing program showed that testing the companions of people attending the HIV clinic yields new HIV diagnoses and has a high rate of linkage to HIV care.(1)

Companion HIV Testing Initiative

In this program, rapid POC HIV testing is voluntary and advertised through flyers around the clinic. People who accompany a clinic client to their appointment can approach clinic staff for a test. Testing is confidential; the relationship to the client who is being accompanied is not asked and no information about the companion’s test results is shared with the client unless disclosure support is requested. Pre- and post-test counselling is part of the POC test process.

Companions whose POC test is reactive (a provisional positive test result) are scheduled to return to the clinic for confirmatory testing. If the confirmatory test is positive, the person is immediately linked to the clinic, which offers access to primary care providers, social workers, substance-use counsellors and financial assistance counsellors.

Testing program finds 5% positivity rate

Between October 2007 and June 2013, 452 companions were tested. Eighteen percent (72) were first-time testers. Ninety-nine percent (450) received their POC test results on the same day.

There were 22 reactive tests and confirmatory testing was performed for 86% (19) of them). All individuals with a confirmed positive HIV diagnosis were engaged in care at the clinic. Over 70% (16) of companions who tested positive through the program had never tested positive before; the overall positively rate (which included people who were previously diagnosed) was 4.9%.

Program acceptable to general clinic clientele

Between January and April 2009, an anonymous survey was distributed to all clients to assess the program’s acceptability among the general clientele of the clinic.

Four hundred respondents completed the anonymous survey. Ninety-six percent approved of the testing program.

What does this mean for Canadian service providers?

Testing programs that target the social networks of people living with HIV increase access to testing in communities of people who may be at higher risk for HIV acquisition. Social networking programs similar to this one are being used by Saskatoon Health Region to test the social contacts of people recently diagnosed with HIV. In Vancouver, St. Paul’s Hospital offers regular HIV testing to the serodiscordant sexual partners of clients engaged in ongoing HIV care.

The UNC program did not require any new funding and operates using the existing infrastructure and staff. This type of clinic-based HIV testing for companions of HIV-positive clients has the potential to significantly increase the number of people living with HIV who know their status and who are linked to care, and could be replicated in HIV clinics across Canada in provinces where rapid POC testing is available.

References

Bischof JJ, Bell LL, Pierce JK, Cooper KL, Heine AD, Quinlivan EB, et al. Detecting HIV Among Persons Accompanying Patients to an Infectious Diseases Clinic: Sexually Transmitted Diseases. 2015 Jan;42(1):54–6.

HIV retention and LTC

HIV retention and LTC

United States
2016

American study shows HIV linkage-to-care and retention programs are cost-saving

A recent American study1 of 12 HIV linkage-to-care and retention programs found that the programs are a cost-saving way to improve the health and well-being outcomes of people living with HIV and to reduce new HIV transmissions.

What types of programs were included in the study?

The 12 linkage-to-care and retention programs served a variety of people living with HIV, including women, trans people, people of colour, prisoners, youth, and men who have sex with men. The goal of each program was to link and retain people diagnosed with HIV who:

  • had never linked to care
  • had been lost to care
  • were at risk of disengaging from care

The programs used a variety of strategies to link and retain people in care, including telemedicine in rural areas, outreach and mobile teams in urban areas, and working with prisoners before their release into the community.

Most of the programs had at least one dedicated staff member who was responsible for working with clients to support them to link and remain in care. These staff members were called care coaches, case managers, linkage-to-care specialists, or navigators. Despite the different titles, they all played similar roles: working with clients to identify their individual barriers to linking to and remaining in care; and supporting them to overcome these barriers by coordinating the services they need. Most of the programs offered multidisciplinary care services to clients, including healthcare, support services, housing supports and substance-use treatment.

How was cost saving calculated?

Over a six-month or 12-month period, each program calculated the payer costs (public and private insurance), the societal costs (payer costs plus the cost to the client), and the cost-saving and cost-effectiveness thresholds associated with each program.

Results

The study researchers concluded that linkage to care and retention programs, such as the ones included in this analysis, were likely an efficient use of resources to address the HIV epidemic.

What does this mean for Canadian service delivery?

We know from estimates in Ontario2 and British Columbia3 that we are not optimally linking and retaining people in HIV care once diagnosed. This research shows that complex, tailored services that support people living with HIV to link to and remain in care may seem expensive but likely cost less than lifetime treatment for a person living with HIV.

Currently, a number of Canadian programs have been developed specifically to link people diagnosed with HIV to care, including Making the Links in Toronto, and the STOP Outreach Team in Vancouver.

References

  1. Jain KM, Maulsby C, Brantley M, et al. Cost and cost threshold analyses for 12 innovative US HIV linkage and retention in care programs. AIDS Care. 2016 Mar 28;1–6.
  2. Gilbert M, Gardner S, Murray J, et al. Quantifying the HIV care cascade in Ontario: Challenges and future directions. Poster presented at: 24th Annual Canadian Conference on HIV/AIDS Research; 2015 May 30; Toronto, Ontario. Available from: http://www.cahr-acrv.ca/wp-content/uploads/2012/10/InfDis_26_SB_MarApr2015_Final.pdf
  3. Nosyk B, Montaner JSG, Colley G, et al. The cascade of HIV care in British Columbia, Canada, 1996–2011: a population-based retrospective cohort study. The Lancet Infectious Diseases. 2014 Jan;14(1):40–9.

Healthcare Provider Mentorship Program

Healthcare Provider Mentorship Program

Canada
2016

Can a mentorship intervention for nurses improve healthcare for people living with HIV?

A Canadian mentorship intervention1 that brings experienced HIV nurses and people living with HIV together with less HIV-experienced nurses has shown that mentorship can improve nurses’ attitudes toward, and knowledge of, issues related to HIV.

The mentorship intervention

The mentorship intervention, which had four sites (two rural, two urban) across Canada, brought together experienced HIV nurses (nurse mentors), people living with HIV (HIV-positive mentors) and less HIV-experienced nurses (nurse mentees) to increase the capacity of nurse-mentees to provide comprehensive HIV care for people living with HIV. The intervention was evaluated through pre- and post-intervention surveys with all three groups of participants.

The content of the intervention and how it was delivered was collaboratively determined by nurse mentor, HIV-positive mentor and nurse mentee participants at each site; the community advisory committee that informed the intervention; and the research team. Participants were able to tailor content and format to their practice environments and learning needs.

At three sites, the intervention consisted of three workshops: one at the beginning of the intervention, one six months later, and the final one six months after that. At a fourth site, only two workshops were held, one at the beginning of the intervention and a final one six months later. This was due to participant preference and time constraints.

The workshops were facilitated by the research team, and a variety of methods were used, including body mapping, videos, guest speakers and case vignettes. The first workshop focused on relationship development and building knowledge of HIV care, treatment and prevention. Discussion centred on key social and political issues that influenced care, and issues related to key affected populations. Topics and structures for the second and third workshops were determined at each site during the first workshop.

Between workshops, monthly group meetings were held to continue discussions among all three groups of participants. These in-person meetings were facilitated by the mentors. Nurse mentors, HIV-positive mentors and nurse mentees discussed the lived experience of people living with HIV, client engagement in healthcare, and interdisciplinary practices in HIV care.

The overall time commitment for the program was two hours weekly for workshops, meetings and interviews for the duration of the intervention (six or 12 months).

Results

At the start of the program, there were

  • 40 nurse mentees (eight to 12 per site)
  • 8 HIV-positive mentors (one to three per site)
  • 8 nurse mentors (one to three per site)

The program was completed by 70% (28) of the nurse mentees and 87% (14) of the mentors .

All of the nurse mentors had specialized in HIV care for more than 10 years and most of the HIV-positive mentors had been living with HIV for more than 10 years. All of the nurse mentees had cared for at least one HIV-positive person during their career, and 71% reported some training on HIV.

Significant increase in self-reported knowledge and changed attitudes among nurse mentees

The study found:

  • a significant increase in preparedness to provide care to people living with HIV among participants who reported being unprepared or uncertain before the intervention.
  • a significant improvement in nurse-mentee HIV-specific knowledge.
  • a significant improvement in nurse-mentee knowledge specific to nursing.

Interviews with nurse mentees supported the positive impact found by the survey. Nurse mentees reported that intervention helped them:

  • develop more positive attitudes toward people living with HIV
  • recognize their preconceptions about clients living with HIV, gay men, people who use drugs and people living with mental health challenges;
  • enhance their ability and their confidence to care for clients with HIV;
  • feel more comfortable sharing their new knowledge with colleagues; and
  • develop a desire to advocate for changes to the health system to improve care for people living with HIV.

Program had positive impact on nurse- and HIV-positive mentors too

There were no significant changes observed in the knowledge, attitudes and practices of the nurse mentors or HIV-positive mentors as measured by the pre- and post-intervention surveys. This was likely due to the high level of experience among mentors.

Nevertheless, both nurse mentors and HIV-positive mentors benefitted from the intervention. Interviews suggested that mentors gained confidence, updated their knowledge, and for HIV-positive mentors, gained an understanding of health service procedure and practice, and better understood themselves.  

What does this mean for Canadian service delivery?

People living with HIV in Canada are not optimally engaged in care.2,3 Many factors may contribute to a reticence among some people living with HIV to access and remain in HIV and other healthcare services, including healthcare-provider stigma. This mentorship intervention demonstrated that positive changes in knowledge, attitudes and practice can take place if nurses are given the opportunity to learn from experienced nurses and people living with HIV. Education and support for clinicians to improve care for people with complex health needs, including people living with HIV, is available in Quebec, Manitoba, Alberta, and British Columbia.

References

  1. Worthington C, O’Brien K, Mill J, et al. A mixed-methods outcomes evaluation of a mentorship intervention for Canadian nurses in HIV care. Journal of the Association of Nurses in AIDS Care. 2016 (in pres).
  2. Nosyk B, Montaner JSG, Colley G, et al. The cascade of HIV care in British Columbia, Canada, 1996–2011: a population-based retrospective cohort study. The Lancet Infectious Diseases. 2014 Jan;14(1):40–9.
  3. Gilbert M, Gardner S, Murray J, et al. Quantifying the HIV care cascade in Ontario: Challenges and future directions. Poster presented at: 24th Annual Canadian Conference on HIV/AIDS Research; 2015 May 30; Toronto, Ontario. Available from: http://www.cahr-acrv.ca/wp-content/uploads/2012/10/InfDis_26_SB_MarApr2015_Final.pdf

ARTAS

ARTAS

Los Angeles County, United States
2016

Short-term health navigation program increases percentage of people living with HIV engaged in care

A navigation program that actively seeks and supports clients who are not engaged in HIV care can successfully link clients to care. A study1 showed that the program, based in Los Angeles County, California, can also significantly increase the percentage of clients with an undetectable viral load.

The Navigation Program

The Navigation Program is a partnership between Los Angeles County Department of Public Health, AIDS Project of Los Angeles, AIDS United, and Johns Hopkins University. The goal of the program is to link to care people living with HIV who are not already well-engaged in care. The program is staffed by six paraprofessional health navigators who have experience working with people living with HIV. The intervention has four components:

  1. Building relationships with clients
  2. Assessing client needs
  3. Linking clients to resources and enhancing client strengths
  4. Transitioning clients to more long-term care at the end of the program

Navigators use clinic records to identify potential participants. Using clinic records and public health databases, the navigators then to try to locate and contact potential participants using phone, text, email, letter or home visit. If this approach is unsuccessful, navigators also look through jail and prison databases, people-finder websites and, if a person has a history of homelessness, by connecting with shelters. Once enrolled in the program, navigators schedule and remind clients about appointments, follow-up on client referrals. After three months in the program, clients are transitioned back to either their home clinic or a new clinic of their choice.

The results

Participants in the study were recruited from seven clinics between January 2012 and August 2014. Eligible participants had to be out of care, which was defined as:

  • no HIV care visits in the previous six to 12 months and a viral load greater than 200 copies/mL;
  • no HIV care visits in more than 12 months;
  • new diagnosis and never in care; or
  • recently released from jail, prison or other institution and with no current regular HIV care provider.

A total of 1,139 clients were identified as being out of care, and 7% (78) were located and enrolled in the program. Of the clients who were contacted, 5% were re-engaged in care through the initial call with a navigator but did not enroll in the program. Clients who did not enroll in the program were in care elsewhere, had left Los Angeles County, had passed away, were in jail, prison or a mental health facility, could not be located, or declined enrollment.

Most program participants were men (78%), Latino (71%), gay (50%), and had an annual income of less than $10,000 (64%). A significant minority identified as Black (18%).

Out of the 78 individuals enrolled in the program:

  • 47% (37) had no history of care in the previous 12 months
  • 32% (25) were deemed to have unstable care (recently released from an institution with no regular HIV care provider)
  • 18% (14) had no HIV care in the last six to 12 months and had a viral load greater than 200 copies/mL
  • 3% (2) were newly diagnosed and had never been in care

Most clients had a number of service needs at the time of enrollment. On average, navigators met with clients five times and clients needed five referrals (mental health, housing/transportation, and financial/employment) while participating in the program. Almost half of the participants (46%) needed fewer than three visits to re-engage in care. Common services required by clients at time of enrollment included:

  • dental care (60%)
  • benefits assistance (43%)
  • medication assistance (42%)
  • food or other basic needs (35%)
  • HIV healthcare (34%)

Almost all clients (94%) were linked to care within 12 months of enrolling in the program. Of the clients who were linked to care, 82% were retained, which is defined as attending a second medical appointment three to 12 months after they were linked. There was a significant increase in the percentage of participants with an undetectable viral load after they were retained in care (63%) compared to 52% at the time of enrollment.

What does this mean for Canadian service providers?

This study has shown that short-term intensive navigation by paraprofessionals can successfully re-engage clients who have not been successfully retained in care. Most clients needed only a phone call or fewer than three visits to be linked to care, and once linked most were retained in care.

There are currently a number health navigation programs in Canada that support clients to engage in care, including Peer Navigation Services in Vancouver, the Chronic Health Navigation Program in Kelowna, the Peer-to-Peer Program in Regina, and the Making The Links program in Toronto.

Canadian practice guidelines on how to provide peer health navigation services to people living with HIV will be published in 2017.

Resource

Health navigation: A review of the evidence —CATIE

References

Wohl AR, Dierst-Davies R, Victoroff A, et al. Implementation and operational research: The Navigation Program: An intervention to reengage lost patients at 7 HIV clinics in Los Angeles County, 2012–2014. Journal of Acquired Immune Deficiency Syndromes. 2016;71(2):e44–e50.

Male Call Canada

Male Call Canada

Canada
2016

Since the beginning of the epidemic, HIV has disproportionately affected gay men and other men who have sex with men (MSM) in Canada. Of the estimated 71,300 people living with HIV in Canada in 2011 (prevalence), 50% were in MSM. Furthermore, an estimated 50% of all new HIV infections in 2011 (incidence) were among MSM, a rate that has remained generally steady across time. Owing to the continuing high rates of HIV prevalence and incidence among MSM, there is a pressing need to understand the attitudes, opinions and behaviours of MSM – and their HIV prevention needs – in order to inform and improve education, policies and programs.

Recently, two important research projects have sought to meet these needs by conducting 1) a national toll-free telephone survey among MSM across Canada and 2) a survey of Canadian AIDS Service Organizations (ASOs) working in MSM health.

Male Call Canada

The national telephone survey – “Male Call Canada” – was a bilingual, university–community collaboration undertaken by academic and community investigators from across Canada. This study aimed to better understand the social contexts of MSM, their attitudes and knowledge towards sex, sexuality, health and well-being, and their understanding of risk behaviours related to HIV and STIs. MSM were recruited through a variety of different mechanisms (including traditional classified advertisements and social media campaigns) and encouraged to volunteer to be interviewed by calling an anonymous toll-free telephone line.

Between October 2011 and February 2012, over 1,200 interviews were conducted over the phone. Calls were received from all of Canada’s provinces and territories. The average age of respondents was 45 years (range 16–89), and the majority (68%) lived in an urban setting. Most respondents (55%) self-identified as gay, with the remainder identifying as straight, bisexual, queer, two-spirit or other. Nationally, 6.6% reported that they were living with HIV.

Some examples of key findings are:

  • Condom use: Approximately 50% reported always using condoms. However, half felt that condoms make sex less pleasurable and a significant proportion (30%) suggested that they would be willing to have sex with a person who is HIV-positive without a condom.
  • HIV testing: The majority (75%) had tested for HIV in the past and 35% had done so in the previous 6 months. For those who had never tested for HIV, the main reasons for not testing were the belief they were HIV-negative (84%) or that they were at low risk of HIV infection (74%).
  • HIV transmission: Overall knowledge of how HIV could be transmitted was high. Half of men (50%) agreed that a man is at an increased risk for HIV if he is a bottom

This is only a snapshot of the information available. A full technical report and 20 graphic novel-like fact sheets are available, which provide a more complete picture of the findings.

National survey of Canadian ASOs

A related project surveyed Canadian ASOs to gain insight into research needs for sexual health promotion among MSM.  In total, 34 staff persons from the Atlantic (13%), Ontario (33%), Pacific (10%), Prairies (13%) and Quebec (30%) regions completed the on-line survey.

Based on the survey results, the investigators made a series of research, programming and policy recommendations, such as the need for:

  • More research studies, both quantitative and qualitative, exploring the lives of rural MSM, youth MSM and the complex issues that have arisen as a result of the criminalization of HIV.
  • Identification and utilization of revenue streams for MSM-related HIV prevention research. Only a minority (27%) of respondents ever had received funding to do their own HIV prevention research for MSM.
  • An increase in the development of research capacity at ASOs to foster more community-based research for MSM, through the increased availability of research tools, access to conferences and the ability to conduct independent research.
  • Development of programs for “hidden” groups of MSM, religious MSM, trans MSM and MSM who don’t identify as gay. These groups were identified by participants as being missed by existing programs or having unmet sexual health promotion needs.
  • Ongoing advocacy efforts to fund HIV prevention programs and staff for MSM. Overall, 33% of respondents reported that their organization did not have a dedicated programming position to work with MSM and 13% said they had not received funding for MSM-specific HIV prevention.
  • Continued HIV prevention programs that target the internet and capitalize on this medium.
  • Reinforcement of existing MSM-related mental health services and expansion to the majority of ASOs.

The final report includes additional recommendations and identifies the ongoing and evolving needs of MSM based on a comparison with previous surveys/assessments.

What do the surveys tell us?

The “Male Call Canada” survey has added to our understanding of the behaviours, knowledge, attitudes and opinions of MSM living in Canada. The findings can be used by those working in HIV to help inform community-level discussions and shape programming and research for this population. The related survey of Canadian ASOs can help organizations, funders and policy makers gain a better understanding of research, programming and policy needs and help to better develop programming and policies for MSM in Canada.

Resource

Sexually transmitted infections and HIV transmission – CATIE Fact sheet

National HIV Testing Day

National HIV Testing Day

United States
2016

What can we learn from an American HIV testing campaign?

A study on the effect that National HIV Testing Day (NHTD) has on HIV testing trends in the United States showed an increase in both the number of tests performed and new HIV-positive test results during the week of NHTD compared to two control weeks. The study also showed significant increases in the percentage of HIV tests in high-risk populations, including men who have sex with men (MSM) and non-Hispanic Black people.

National HIV Testing Day is used in the United States to promote and increase HIV testing. The event takes place annually on June 27th and hundreds of local events take place. Most local events offer HIV testing and are accompanied by media and social marketing campaigns that improve knowledge about HIV prevention, testing and care services; address barriers to getting tested; and encourage HIV testing.

The objectives of National HIV Testing Day are to encourage people to:

  • get tested for HIV
  • become aware of their HIV status
  • get linked to prevention, care, and treatment services
  • work to reduce the stigma associated with HIV

Although NHTD has been running in the United States since 1995, no such day has ever been established in Canada.

The study

The week around NHTD in 2010 (June 24–30) was compared to two other weeks that year, called control weeks. These weeks (control week 1: January 7–13 and control week 2: August 12–18) were chosen because no known HIV testing or awareness campaigns were conducted nationally within four weeks of these periods and no major national holidays were within a week of these periods.

The results1

In 2010, 52 health departments conducted 161,844 CDC-funded testing episodes during the three weeks included in the study. During NHTD week in 2010, there were significantly more tests conducted compared to both the control weeks (63,914 tests compared to 48,748 tests during control week 1 and 49,182 tests during control week 2).

During NHTD week, there were significantly more newly identified HIV-positive test results compared to both control weeks (467 during NHTD week compared to 367 in control week 1 and 356 in control week 2).

The profile of people who tested also changed during NHTD. The study showed that, compared to control weeks 1 and 2:

  • The percentage of people aged 20–29 who tested during NHTD week was significantly lower (4.5% and 1.8% lower, respectively).
  • The percentage of people aged 50 years of age or older who tested during NHTD week was significantly higher (2.7% and 1.6% higher, respectively).
  • The percentage of people who were non-Hispanic white who tested during NHTD week was significantly lower (2.8% and 1.4% lower, respectively).
  • The percentage of people who were non-Hispanic Black who tested during NHTD week was significantly higher (2.9% and 1.9% higher, respectively).
  • The percentage of people who were MSM who tested during NHTD week was significantly higher (0.8% and 1.0% higher, respectively).
  • The percentage of people who were low-risk heterosexuals who tested during NHTD week was significantly higher (2.0% and 1.8% higher, respectively).

The study showed that during NHTD week, the percentage of people who were tested with a rapid test compared to control weeks 1 and 2 was significantly more (6.6% and 4.9% more, respectively). The study also found that the percentage of people tested in a non-healthcare setting during NHTD week compared to control weeks 1 and 2 was significantly higher (13.1% and 10.1% higher, respectively). Finally, compared to control week 1 (but not 2) the percentage of people who received their test result was significantly higher (3.0%). 

What does this tell us about the potential of a National HIV Testing Day in Canada?

This study showed that NHTD increased overall testing numbers and newly identified HIV-positive test results compared to two control weeks. It also demonstrated an increase in testing among certain high-risk populations, including non-Hispanic Black people and MSM but not among others, such as Hispanic or Latino people.

The use of rapid test technology – 66% of all tests performed during NHTD were rapid tests – may have been key to increasing the ability of service providers to perform more tests. The expansion of testing sites to non-healthcare settings during the campaign may also have been important. High rates of returned test results (81%) during NHTD week tells us that a majority of testers learned their HIV status.

A similar national HIV testing day in Canada could potentially increase the number of people who test for HIV and therefore know their status. An understanding of the barriers to testing among specific at-risk populations should be used to better inform the social marketing approaches of any campaign to ensure that these barriers are addressed.

Resources

HIV Screening and Testing Guide – Public Health Agency of Canada

Reference

Van Handel MM, Mulatu MS. Effectiveness of the U.S. National HIV Testing Day campaigns in promoting HIV testing: Evidence from CDC-funded HIV testing sites, 2010. Public Health Reports. 2014 Oct;129:446–54.

Routine testing programs

Routine testing programs

Could routine testing help reduce the number of people who are unaware they are HIV positive?

In 2011, an estimated 25% of the 71,300 Canadians living with HIV were unaware of their infection.1 People who haven’t been tested and diagnosed are unable to benefit from linkage to care, support and treatment, which improve health and reduce HIV transmissions.

In 2013, the Public Health Agency of Canada released an HIV Screening and Testing Guide2 that “seeks to reduce the number of undiagnosed HIV infections in Canada by offering a framework for care providers to explore options that will enhance their ability to provide HIV testing, as well as to better tailor their testing approaches to meet the specific needs of their practice and clients.” One of the recommendations to improve HIV testing in Canada is to add the offer of an HIV test to periodic routine medical care. Could this help to improve diagnosis of HIV?

Routine testing in New York and New Orleans

Periodic routine testing was implemented in two healthcare settings, in New York City and New Orleans,3 between 2011 and 2013 and was very successful at diagnosing HIV infections and then linking people to care.

In New York, the percentage of people who received an HIV test increased from 8% before the introduction of routine testing to 56% after its implementation. Between 2011 and 2013, 32,534 people were tested for HIV of whom 0.45% tested positive. Of the people who tested positive, 99% received their test result and 81% were linked to care.

There were two routine testing sites in New Orleans. At the first site, the percentage of people who received an HIV test increased from 17% before the introduction of routine testing to 26% after its implementation. At the second site, testing increased from 3% to 17%. In 2012, 11,257 people were tested for HIV of whom 0.94% tested positive. All people who tested positive received their test results and 74% were linked to care.

A Canadian model

Routine testing programs such as those in New York and New Orleans could serve as models for adaptation. However, Canadians don’t need to look that far for examples of routine testing programs. In Vancouver, the routine offer of an HIV test was integrated into family practices and acute care settings as part of the Vancouver STOP project. Routine testing in these settings was just one part of a multi-pronged testing strategy, which continues to include targeted testing for people at ongoing high-risk for HIV infection. In the three acute care settings, for example, 10,102 HIV tests resulted in a positive HIV diagnosis in 0.3% to 0.8% of HIV tests. These rates are quite similar to the rates found in New York and New Orleans. These diagnostic rates are higher than the generally accepted cost-effectiveness threshold of 0.1% in acute care settings.

A promising approach

These results show us that the routine offer of an HIV test in health care, in addition to other testing initiatives, can increase awareness of HIV status among those who may not present for HIV testing on their own. It can also result in high levels of engagement in ongoing care for those who are diagnosed with HIV.

References

  1. Public Health Agency of Canada. Summary: Estimates of HIV Prevalence and Incidence in Canada, 2011. Surveillance and Epidemiology Division, Professional Guidelines and Public Health Practice Division, Centre for Communicable Diseases and Infection Control, Public Health Agency of Canada, 2012. Available at: www.phac-aspc.gc.ca/aids-sida/publication/survreport/estimat2011-eng.php
  2. Public Health Agency of Canada (PHAC). HIV screening and testing guide. Ottawa: PHAC; 2013. Available from: http://www.catie.ca/sites/default/files/EN_HIV-Screening-Guide-2013.pdf [accessed April 1, 2014]
  3. Xia Lin X, Dietz PM, Rodriguez V, et al. Routine HIV Screening in Two Health-Care Settings — New York City and New Orleans, 2011–2013. Morbidity and Mortality Weekly Report. 2014 Jun 27:63(25);537–41. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6325a2.htm

Queer Women’s Conversations

Queer Women’s Conversations

Toronto and Calgary, Canada
2016

A brief, group intervention reduces HIV and STI sexual risk practices among queer women

Research suggests that up to 20% of lesbian, bisexual and queer women have been diagnosed with a sexually transmitted infection (STI) in their lifetime1,2,3,4 and the use of safer sex practices are low among this population.2,5 Despite the data to support the need for interventions to reduce risky sexual practices to prevent STI transmission among queer women, there are few Canadian HIV and STI prevention programs specifically tailored to their needs.

Queer Women’s Conversations

Queer Women’s Conversations is a group-based psycho-educational HIV and STI prevention intervention for lesbian, bisexual and queer women and other women who have sex with women. The intervention was adapted from Many Men, Many Voices, a health promotion program for young gay black men first developed in the United States.

The intervention involved six consecutive sessions (lasting two to three hours) conducted at weekend retreats held in Toronto and Calgary in March and April 2014. Content was delivered using a variety of techniques such as small and large group discussions, role-play, and arts-based methods.

Session topics covered included:

  • Sex, bodies, pleasure and safer sex knowledge
  • Sexual stigma, sexuality, barriers, and facilitators to safer sex, emotional and mental health
  • Power relations, healthy relationships, communication skills, safer sex self-efficacy, and intimacy
  • Internalized stigma, self-esteem, self-acceptance, and resilient coping
  • Social and health services, community resources and support systems, and strategies for building and connecting to LGBTQ communities.

There were 44 participants in the pilot study of Queer Women’s Conversations. The women were asked to complete a survey before the intervention to determine baseline answers to the survey questions. Participants were asked to complete the survey again immediately after the intervention and again six weeks later. The final survey was completed by 38 of the 44 participants.

Overall, participants reduced their sexual risk practices significantly, immediately post-intervention and six weeks later when compared to baseline data.6

The research also showed that Queer Women’s Conversations had a significant positive impact on participants’ belief that they could use safer sex methods (self-efficacy), STI knowledge, and sexual stigma immediately after the intervention and six weeks later, compared to baseline data.

Increases in some social support outcomes (reliable alliance and guidance), and in community connectedness were observed immediately post-intervention compared to baseline data, but these positive impacts were not observed six weeks after the end of the intervention.

The intervention did not impact outcomes such as resilient coping, self-esteem, depression, and social support dimensions such as attachment, social integration, opportunity for nurturance and reassurance of worth.

A possible program model for queer women’s sexual health    

The study is one of the first of its kind to demonstrate that a brief HIV and STI prevention program can impact the sexual risk practices of queer women. Although there are a number of promising Canadian approaches to HIV and STI prevention among youth, African, Caribbean and Black communities, Aboriginal communities, and recently, the emergence of Totally Outright in Canada for queer men, Queer Women’s Conversations has the potential to fill a gap in the continuum of HIV and STI prevention services in Canada.

References

  1. Steele LS, Ross LE, Dobinson C, et al. Women’s Sexual Orientation and Health: Results from a Canadian Population-Based Survey. Women & Health. 2009 Oct 19;49(5):353–67.
  2. Pinto VM, Tancredi MV, Neto AT, Buchalla CM. Sexually transmitted disease/HIV risk behaviour among women who have sex with women. AIDS. 2005;19:S64–9.
  3. Bauer GR, Welles SL. Beyond assumptions of negligible risk: sexually transmitted diseases and women who have sex with women. American Journal of Public Health. 2001;91(8):1282–6.
  4. Logie C, Navia D, Loutfy M. Correlates of a lifetime history of sexually transmitted infections among women who have sex with women in Toronto, Canada: results from a cross-sectional internet-based survey. Sexually Transmitted Infections. 2014. [Epub]
  5. Schick V, Rosenberger JG, Herbenick D, Reece M. Sexual behaviour and risk reduction strategies among a multinational sample of women who have sex with women. Sexually Transmitted Infections. 2012;88(6):407–12.
  6. Logie CH, Lacombe-Duncan A, Weaver J, et al. A Pilot Study of a Group-based HIV and STI Prevention Intervention for Lesbian, Bisexual, Queer, and Other Women Who Have Sex with Women.AIDS Patient Care and STDs. 2015;29(6).[Epub ahead of print]

Linkage to Care Intervention

Linkage to Care Intervention

Wisconsin, United States
2016

An intensive, time-limited linkage-to-care intervention positively impacts engagement in HIV care

In 2014, UNAIDS proposed an ambitious set of targets for the global scale-up of HIV treatment. This approach to the HIV response is based on research showing that early, life-long HIV treatment can dramatically improve the health of people living with HIV1 and can also dramatically reduce HIV transmission.2

Despite the clear benefits of care and treatment, Canada is not meeting UNAIDS targets that, if achieved, may end the epidemic spread of HIV by 2030.3 By 2020, UNAIDS proposed that:

  • 90% of all people living with HIV will know their status;
  • 90% of all people with diagnosed HIV infection will receive sustained ART;
  • 90% of all people receiving ART will have viral suppression (undetectable viral load).

If these targets are achieved, 81% of all people living with HIV will be on treatment and 73% will have an undetectable viral load. Although Canada has not published national data for the UNAIDS targets, data from British Columbia and Ontario show that Canada is not doing as well as other countries. For example, only 35% of people living with HIV in British Columbia are estimated to have an undetectable viral load and only 27% to 40% of people living with HIV in Ontario have an undetectable viral load.4,5 This is significantly lower than the  UNAIDS target of 73% and means we need to do more to engage clients across the continuum of care.

To achieve the 90-90-90 goals, people living with HIV will need to be engaged in their HIV care. Effective programs that improve engagement in HIV care for people living with HIV are needed to help us achieve the UNAIDS targets.

Wisconsin’s Linkage to Care Intervention

Wisconsin’s Linkage to Care Intervention assigns linkage-to-care specialists (non-medical professionals who receive specific training on the basics of HIV disease transmission, progression and treatment, principles of case management, motivational interviewing, and professional ethics) to HIV-positive participants who are newly diagnosed with HIV, recently released from prison, or who are not currently engaged in HIV medical care.

Specialists provide and coordinate services, referrals and appointments, attend appointments with participants, and help participants navigate the healthcare system. Specialists can work with participants for up to nine months; each specialist has a maximum of 15 clients on their case load at any given time.

The study

Between February and August 2013, 16 participants from the pilot phase of the Linkage to Care Intervention were interviewed about their experience of the program.

Overall, participants reported that it was the relationship with their linkage-to-care specialist that was critical to their successful engagement in HIV medical care.6 The personal connection with their specialist helped participants become comfortable with medical care despite perceptions and experiences of HIV stigma, which had kept them from getting care in the past. Participants also reported that the relationship with their specialist was a motivator for prioritizing their health in a way that they had not done before.

Fuel to the fire

This study shows that an intensive, time-limited linkage-to-care intervention is acceptable to participants. It also demonstrates that interventions which ensure the development of strong relationships between participants and service providers can have a positive impact on client engagement in care.

This study adds to the growing body of evidence that health navigation for people living with HIV can have a positive impact on engagement, linkage to and retention in care. There are a numberof similar navigation programs already operating in Vancouver, Kamloops and Regina.

References

  1. Samji H, Cescon A, Hogg RS, et al. Closing the Gap: Increases in Life Expectancy among Treated HIV-Positive Individuals in the United States and Canada. Okulicz JF, editor. PLoS ONE. 2013 Dec 18;8(12):e81355.
  2. Cohen M, Chen YQ, Macauley M, et al. Prevention of HIV-1 Infection with Early Antiretroviral Therapy. New England Journal of Medicine. 365(6):493–505.
  3. Joint United Nations Programme on HIV/AIDS (UNAIDS). 90-90-90: An ambitious treatment target to help end the AIDS epidemic [Internet]. Geneva, Switzerland: UNAIDS; 2014 Oct [cited 2014 Nov 18] p. 33. Available from: http://www.unaids.org/sites/default/files/media_asset/90-90-90_en_0.pdf
  4. Nosyk B, Montaner JSG, Colley G, et al. The cascade of HIV care in British Columbia, Canada, 1996–2011: a population-based retrospective cohort study. Lancet Infectious Diseases. 2014 Jan;14(1):40–9.
  5. Gilbert M, Gardner S, Murray J, et al. Quantifying the HIV Care Cascade in Ontario: Challenges and Future Directions [Internet]. Poster presented at: 24th Annual Canadian Conference on HIV/AIDS Research; 2015 May 30; Toronto, Ontario. Available from: http://www.cahr-acrv.ca/wp-content/uploads/2012/10/InfDis_26_SB_MarApr2015_Final.pdf
  6. Broaddus M, Hanna CR, Schumann C, Meier A. “She makes me feel I’m not alone”: Linkage to Care Specialists provide social support to people living with HIV. AIDS Care. 2015 Apr 9.
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