2013

Connecting the Dots from Housing to Health

For people living with HIV in Vancouver who are homeless, under-housed or street involved, finding safe and suitable accommodations can be difficult with a lack of options. This is starkly demonstrated by the existence of long waiting lists for HIV-specific housing in Vancouver, as elsewhere. As of 2011, these lists had more than 400 clients on them in some cases, representing an estimated wait time of more than two years. For some people, the added challenges that can accompany trauma, addictions or mental health concerns often lead to situations in which accessing and adhering to an HIV treatment regimen may be difficult, impossible or simply not a priority. For people in these situations, HIV infection can go uncontrolled for a long time, significantly damaging the immune system. That, in turn, can allow the virus to develop resistance to treatments, leading to AIDS and even death. Housing can often be the missing link required to get to the point where managing one’s HIV infection is a realistic priority.

In recognition of the lack of accessible, affordable housing options for people living with HIV in Vancouver, the Vancouver STOP Project, the team responsible for the implementation of the STOP HIV/AIDS Project in this city, partnered with RainCity Housing and Coast Mental Health. The following Program Element describes these partnerships as well as the three innovative strategies they used to address the urgent housing needs of Vancouver STOP Project clients: a housing stabilization support program; supported independent living subsidies (SILS); and access to units in a supported housing building.

Making Links to Housing

Rather than develop a separate housing strategy for clients parallel to other housing agencies in Vancouver, the Vancouver STOP Project partnered with and funded two established housing providers that offer services to a broad range of people in the city, including but not limited to people living with HIV: RainCity Housing and Coast Mental Health.

Both RainCity Housing and Coast Mental Health have proven track records in providing housing solutions for people living with mental illness, addictions and other health challenges. Since 1982, RainCity Housing has provided progressive, compassionate shelter and housing to people in the Lower Mainland who are living with mental illness, addictions and other challenges. Coast Mental Health was established in 1972 and provides housing, employment, community and emotional support for people living with mental illness by providing practical support.

Each agency was funded to hire 1.4 additional full-time equivalent housing workers. These staff work almost exclusively with clients living with HIV and are intensively engaged with a city-wide, clinical HIV outreach team, also funded by the Vancouver STOP Project, called the STOP Outreach Team. This team is an interdisciplinary group of nurses, outreach workers, social workers, peers and others who work to expand access to low-barrier HIV services and improve engagement in HIV treatment, care and support for some of Vancouver’s most marginalized people.  

The partnership that was established and solidified by the newly funded housing workers is unique.  These staff members were intentionally hired to act as a critical link between the STOP Outreach Team and the support required to obtain and maintain housing. These initiatives allow for a level of integration rarely seen between healthcare providers and housing workers. This often involves daily or even hourly communication about clients so that all members of the team are ready and able to provide support for any crisis or time-sensitive situation. For more information on this team, please see the STOP Outreach Team case study in Programming Connection.

While it may seem obvious that having appropriate, stable housing is important to people’s health, the relationship between health and housing is complex. Not only does housing affect health, but people’s health -- including their possible substance use, mental health concerns and stage of HIV infection -- can significantly affect the type of housing best suited to them, as well as the support required to obtain and maintain it. For clients whose health concerns had historically made it difficult or impossible to find stable housing, the extra support provided by this collaboration allowed for deeper insight and flexibility into their unique needs. 

Tailored Housing Solutions

No single housing solution is desirable, suitable or appropriate for every person. For example, while some people may appreciate and greatly benefit from housing that integrates support such as medication dispensing/reminders and regular meals, others may fare better simply having access to independent living. Similarly, the type of housing support people require can vary widely. For someone dealing with homelessness, it may mean simply having a safe bed to sleep in; for others, it involves help moving from temporary to more long-term housing. Some people simply need short-term assistance to maintain the housing they already have.

The role of the housing workers funded by the Vancouver STOP Project was not only to help homeless STOP clients find housing, but also to provide any support required to obtain and maintain it. This additional support consisted of assistance with connections to community health and social service resources, move-in and move-out assistance, coaching in the acquisition and maintenance of independent living skills, advocacy in legal and medical affairs, and intervening in crisis situations that might affect the clients’ health and/or tenancy. This extra support proved to be very important in ensuring STOP clients’ ability to maintain their housing. For some clients who came from extended periods of homelessness, adjusting to living in more collective spaces where community norms required particular behaviours (such as attention to noise) sometimes proved challenging. Given the importance of stable, consistent housing in adhering to treatment and effectively managing their HIV infection, this additional support proved to be the key that could make the difference between clients’ maintaining housing or facing eviction.

The Vancouver STOP Project funded three different types of initiatives to address these varied needs.

Stabilization Support Program

At any given time, a minimum of 10 Vancouver STOP Project clients were connected to the Stabilization Support Program at RainCity Housing. Clients referred to this program by the STOP Outreach Team were homeless, almost or totally disconnected from any services, and in a moderately or extremely poor state of health. In these situations, when the STOP Outreach Team agreed with a client that finding access to housing was a priority, the housing outreach worker at RainCity Housing was called to provide support in the process of finding suitable housing, transitioning into that housing, and maintaining the housing once it was found.

Having a dedicated housing outreach worker at RainCity Housing was a deciding factor between remaining homeless and being able to access more stable housing for many STOP clients. The housing outreach worker could facilitate access to shelter beds at RainCity Housing, and was also well acquainted with the other shelter and housing options throughout Vancouver.

Even though the housing outreach worker was based at RainCity Housing, a great deal of work was done outside of the office as the structure of the Stabilization Support Program was not restricted to finding housing locations at any particular agencies or locations. This allowed flexibility to work with clients wherever they were and to continue providing support throughout the entire transition from homelessness to housing, even if the client’s needs changed or they were evicted. Importantly, even after clients were discharged from the housing outreach worker’s active caseload, the worker gave priority to supporting the client in a crisis if their housing became threatened at any time. This integrated and flexible collaboration between a client’s housing and other support providers, such as the STOP Outreach Team nurses, enhanced the overall level of support each could give to their clients, at all points in the process of finding and maintaining housing.

Supported Independent Living Subsidies (SILS) – Temporary and On-Going

Some Vancouver STOP Project clients who were homeless and referred to RainCity Housing’s housing outreach worker did not fare well in supportive housing situations. For these STOP clients, moving directly into independent market housing was the best fit, rather than transitioning through shelters or other more temporary solutions. While disability assistance in B.C. provides about $375 per month for shelter, low-rent independent housing buildings can cost from $600 to $1,000 per month, if not more. Through the SILS project, approximately 10 people were offered a rent subsidy of up to $400 per month, which acted as a top-up to ensure they could get and maintain housing they might not have been able to afford otherwise. This money could make the difference between homelessness and decent housing. SILS therefore acted as a buffer to help those clients on the edge of homelessness because of a gap between their income and living expenses.

Temporary SILS

One of the interesting innovations that arose from the RainCity Housing-STOP partnership was the idea of temporary SILS. This variation on the more long-term SILS grew from the realization that, for many clients, it was not on-going financial assistance that was required, but financial help with one-time or short-term situations where their income was not sufficient to get or maintain housing. Temporary SILS were often useful during periods of transition for STOP clients, mostly when an appropriate housing option became available but the costs associated with moving into that housing, such as damage deposits or first and last months’ rent, were too high.

Another relatively common situation occurred when STOP clients found suitable housing that was only slightly more expensive than the $375 provided by disability assistance. In these situations the client, supported by the housing outreach worker, was sometimes able to obtain the additional financial support required, but needed a small, short-term top-up until their applications for such support was processed and approved.

For clients accessing addictions recovery programs and taking antiretroviral (ARV) medications and methadone, becoming homeless for even short periods of time can mean huge setbacks and result in many of these achievements unravelling. For these clients, SILS proved to be extremely important to obtaining stable housing or taking advantage of better housing opportunities when they arose.

Access to Supportive Housing

Serendipitously, Coast Mental Health was preparing to open a nine-storey, 96-resident supported housing building (the Pacific Coast Apartments) at the same time the Vancouver STOP Project was getting underway. This building was specifically intended to provide housing for people who would otherwise be homeless, at risk of homelessness, or living in substandard housing. Given the considerable support infrastructure integrated into this housing, including a 24-hour on-call clinical service, pharmacy and property management, this site was a good fit for those STOP Project clients who could benefit from housing that also provided extra support. For clients who were on but not able to adhere to their ARV treatments, the added assistance of daily meals and medication reminders helped them achieve a consistent routine and gave them increased stability.

Providing supportive housing to STOP clients at the Pacific Coast Apartments resulted in a range of outcomes, many of which are not immediately apparent when looking at project reports or statistical evaluations. For example, some clients who had been homeless for long periods of time were so ill when they finally accessed housing that their HIV infection (and other health concerns) could not be controlled; for these clients, the housing functioned like a hospice where they were cared for and were able to die in a respectful environment. For others, the additional support and stability gave them the time needed to gain weight, access services such as addictions treatment, and eventually reach a state of health and well-being that they could seek and maintain independent housing. Staff noticed that even clients who eventually left the housing because they did not like the structured support and communal environment often left healthier and better rested than when they entered. This allowed many STOP clients to improve access and adherence to their treatment regimens and for some it resulted in dramatic increases in CD4 counts.

From Housing to Health

The partnerships with housing agencies developed through the Vancouver STOP Project revealed just how important the integration between housing and health really is, and how much of a difference access to appropriate housing can make. For instance, as of January 2012, Coast Mental Health had filled 23 out of 25 units. On admission, only 12 percent (three people) had a viral load less than 200 copies/mL. In a matter of months, 76 percent had a viral load less than 200 copies/mL.

These collaborations demonstrated that while housing is a vital component of people’s ability to adhere to their HIV treatment regimen, a great deal of other support must be in place for them to take advantage of newly found housing. These supports, which can be medical, social or financial, work best when they come from an integrated team of service providers who work together flexibly to provide unique and tailored assistance to STOP clients who are homeless or at serious risk of homelessness.

 

2013

Out of the Clinic and Into the Community

Understandably, not everyone feels comfortable walking into a sexual health clinic or asking their doctor for sexual health-related services. Concerns of privacy, stigma related to sexually transmitted infections (STIs) and HIV, and accessibility are just some of the reasons why gay, bisexual and other men who have sex with men (MSM) may not access sexual health services and education in clinic-based locations.  A 2011 community consultation report by the Health Initiative for Men¹ suggested that for MSM in Vancouver this can be the case:  out of almost 100 men surveyed at outdoor sex venues, two-thirds expressed a lack of sexual health information, less than half reported male sex partners to their doctors and three-quarters were in favour of offering HIV and STI testing at outdoor venues.

Given that in 2011 gay, bisexual and other MSM in Vancouver represented more than 60 percent of new HIV infections in Vancouver, the Vancouver STOP Project employed a strategy used in cities across North America to provide sexual health services to MSM who might not otherwise access them:  bathhouse testing and mobile HIV testing.

Taking Services to the Community

Both the bathhouse and mobile testing initiatives were implemented through the leadership of the STOP Outreach Team, an interdisciplinary clinical team that works across the city of Vancouver to expand HIV testing and engagement in care. The mobile testing project was developed in partnership with YouthCO, a community-based agency in Vancouver. These initiatives involved the creation of mini satellite sexual health clinics where clients can access a full range of HIV and STI testing, treatment and counselling services from a registered nurse. These services are similar to what clients can expect to find at a sexual health clinic, but outside of a traditional clinic setting. Both projects provide essentially the same services by STOP Outreach Team nurses. The primary difference between them is where the services are offered: one is in Vancouver bathhouses; the other is in multiple, changing locations via an outreach van.

Bathhouse-based HIV Testing Project: In this initiative, a STOP Outreach Team nurse worked with bathhouse owners to set up and provide services in a room converted into a small clinic in each bathhouse. Three bathhouses in Vancouver participated.

Mobile HIV Testing Pilot Project: Dubbed “Know on the Go” (KOTG), for this initiative the STOP Outreach Team partnered with YouthCO to deliver services. YouthCO converted a van into a clinic on wheels, promoted the project, determined times and locations to situate the van for outreach and provided outreach workers to inform and educate people when the van was on location.

The following programming element highlights how the STOP Outreach Team approached the provision of sexual health services in unconventional locations.

Working with – and in – the community

Moving sexual health services from a clinic into community-based sites requires answering a significant number of questions:  How will the community perceive the service? Will people access the service? How can services be provided without having them be seen as coercive or pushy? The answers to these questions were difficult to predict and so numerous strategies were employed to ensure the community received the services as well as possible.

Community Consultations

To determine how to best meet the HIV testing needs of gay men and other MSM, the Vancouver STOP Project partnered with a number of leading gay men’s health organizations and community representatives to form a Gay Men’s Reference Group. This group was tasked with the exploration of new strategies for outreach and service provision.

The group highlighted a number of priorities to be taken into consideration when providing site-based services, such as ensuring the privacy of clients, providing culturally safe services and maintaining the same standard of care as a clinical setting. These were reflected in a document titled “Principles for Provider-Initiated Testing External to Healthcare Venues” that the Vancouver STOP Project used to help structure these services. For more information on these priorities, please see below. 

Getting Set Up

The STOP team and YouthCO aim to provide the same quality, level and variety of services through their community-located testing services as would be provided in a clinic. These include the ability to test and treat a range of STIs and offer HIV testing with rapid point-of-care (POC) technology as well as standard blood draws. Two key issues had to be addressed to ensure this would be possible: first, how to create mini satellite clinics in nontraditional settings; and second, how to develop strong relationships with business owners and other stakeholders, such as park staff, at outreach locations.

Creating Satellite Clinics

Providing comprehensive sexual health services via satellite clinics required overcoming a number of logistical challenges that included ensuring access to adequate clinical supplies onsite and establishing a process to get test samples to a lab. The Vancouver STOP Project addressed this issue by working from an existing, standard sexual health clinic run by Vancouver Coastal Health. The mini satellite bathhouse and mobile clinics rely on this existing infrastructure to obtain necessary supplies, such as POC tests and treatments such as antibiotics.  After work shifts are completed at the satellite clinics, test samples are taken either directly to the lab for testing, or to the sexual health clinic where they are batched with all of the samples obtained that day at the clinic.

Beyond a few logistical challenges, such as issues of what to do with samples that were taken after the lab closed, STOP Project nurses found they had the time and space to provide more in-depth, broad services to clients than they might have had in the clinic. In clinic-based settings, where there is often a higher patient load, services are time limited and therefore nurses must be more focused on providing a discrete set of services. Providing services in a non-clinic environment, however, enables nurses to spend longer with their clients and discuss many of the broader issues and health concerns impacting their lives, such as substance use, mental health or other non-sexual health-related concerns that may be more urgent for them.

Developing Relationships

For both the bathhouse and mobile testing projects, building strong relationships with the outreach sites was critical. A significant investment of time and relationship building over multiple meetings was required to ensure the community would receive the services as positively as possible.

When an outreach site was selected for the mobile testing van, YouthCO reached out to the venue (or park officials when at public parks) to let them know about the service to ensure there would be a good reception. Similarly, STOP Outreach Team nurses developed strong relationships with bathhouse owners.

One of the most common concerns voiced through the relationship-building process was the potential for negative community perceptions, in that providing services onsite would “ruin the fun” for clients. Ensuring a passive approach to service provision was an important aspect of addressing concerns about invasion of space. Rather than actively approaching people and encouraging testing, nurses simply make their presence known, either through signs, announcements on the bathhouse PA system or simply by their physical presence when in the KOTG van.

Relationships with bathhouse owners have continued to improve as they perceive the nurses as an “added service” demonstrating their interest and investment in their community’s health. The attractiveness of bathhouse-based services to some clients was so evident that bathhouses started advertising on their event calendars when testers would be available. Bathhouse owners have found that some clients come to the bathhouse specifically to access sexual health services.

A shift in culture

Providing services in venues where people may not expect them requires open, flexible and dynamic strategies from the nurses providing testing. For instance, some clients may have consumed alcohol or other substances prior to inquiring about testing. Others may not feel prepared to receive certain services or, in the case of POC testing, an HIV test result. Further, STOP nurses are aware that they have entered and are providing services in environments that can be highly sexualized. Nurses use a variety of strategies to function appropriately, effectively and safely within these unique environments. The nurses take a friendly, open approach when potential clients seemed interested in the services they are providing. Maintaining a jovial attitude while setting consistent boundaries by clearly communicating their role allows nurses to be present and professional in a sex-positive atmosphere.

Interactions with patrons can range from answering a few questions informally to describing the services they can provide prior to asking a patron whether they are interested in them. No two clients necessarily receive the same service: nurses engage in a discussion with clients to determine their state of mind and suggest tailored testing options to determine the most appropriate service(s). For instance, if through discussions the nurse and client agree it is not the best time for the client to get tested, the client is referred to other services and/or testing locations.  Alternatively, if it is agreed the client wants to take a test but not receive results that day or in the bathhouse/mobile van, a nurse will offer to provide a standard blood-draw HIV test so the client can get results from the nurse at another time and location where they feel more comfortable. Often this second option is particularly appealing to clients when they are informed that the standard blood draw also includes a nucleic acid amplification test (NAAT). This is largely because the window period of the NAAT test is 10-12 days rather than the 12 weeks of the POC antibody test, meaning the NAAT test may reflect more recent high-risk activities.

Measuring Success

With both the mobile and bathhouse-based venues, project co-ordinators were aware some community members might disapprove of their presence. Indeed, some people frequenting venues where STOP was providing community-located services said they would not want to access services in that setting and would prefer to attend a clinic. Through client satisfaction surveys and informal conversations with those who did access the services, the STOP Outreach Team nurses generally found reaction to be very positive. Many community members were happy to see the services available and found them convenient. While venue-based sexual health services were not for everyone, those who did use them appreciated their availability and were happy with the quality of services.

Performance results of both the KOTG mobile testing service and bathhouse testing project have shown that each project provides an opportunity for HIV and STI testing in communities of people who may not get tested otherwise.

The bathhouse testing project determined a 3 percent HIV-positivity, significantly above the widely accepted 0.01 percent threshold for cost-effectiveness. Of those patrons who did test positive for HIV, more than 64 percent were 35 years or younger, 27 percent of those diagnosed with HIV were diagnosed when they were already eligible for treatment (at a CD4 count of less than 500), and 18 percent had never been tested for HIV before.

KOTG also reaches an important demographic: evaluations found that 10 percent of people using the service had never been tested for HIV, 18 percent had never been tested for STIs, and 45 percent had not had an HIV test in more than one year.

Nurses have noted, however, that beyond statistics a great deal of their success has been in the day-to-day interactions with patrons of the spaces where they are providing services. Being present, approachable and friendly has enabled them to develop good relationships with the community of people they interact with and helps to normalize the idea of sexual health and HIV/STI testing. STOP Outreach Team nurses have also found that while STIs and HIV may initially bring someone to their clinic, a far greater range of health and psychosocial issues beyond HIV and STIs arise, giving nurses the opportunity to address these health concerns or make referrals to other services. In this way, the nurses are able to provide sexual health services while also incorporating a broader perspective on gay men’s health. If clients require any type of follow-up or post-testing support, nurses make sure to obtain their contact information and make themselves available at their home clinic for further consultations.

The KOTG and bathhouse pilot projects show it is possible to provide comprehensive sexual health services in nontraditional settings. By developing strong relationships, maintaining a passive approach and providing flexible and individualized services, clients who may not otherwise access services are given the opportunity to initiate contact with healthcare providers. Importantly, this initial contact can move far beyond simple provision of STI/HIV screening to include and improve access to on-going services and care. This gives clients the opportunity to address other aspects of their health and well-being that may impact their risk for acquiring HIV or, if they are HIV-positive, to address broader health concerns in order to manage their HIV effectively.

Contact information

Geoffrey Ford, RN BScN
Nurse Educator, STOP HIV Outreach Team
Vancouver Coastal Health
604-218-4706

Jesse Brown
jesseb@youthco.org
YouthCO AIDS Society
Vancouver BC
Phone: 1-604-688-1441
Toll Free (in Canada): 1-855-YOUTHCO (968 8426)

References

1. Anderson I. Community Consultation Final Report [Internet]. Vancouver, B.C.: Health Initiative for Men; 2011. Available from: http://checkhimout.ca/assets/uploads/files/HIM_Community_Consultation_Report_Final.pdf