Vancouver, B.C.
2020

The Molson Overdose Prevention Site (OPS) in Vancouver co-locates a supervised consumption service, a drug-checking service, a service for injectable opioid agonist treatment and a hydromorphone tablet distribution program. The hydromorphone tablet distribution program is a safe supply program that provides a regulated alternative for people at high risk of overdose from the fentanyl-contaminated, illicit opioid supply. Factors that facilitate engagement in the safe supply program include its low-threshold model, co-location within the OPS and the flexibility and choice that the program offers to participants. Barriers to engagement include the OPS’ limited operating hours, dosage restrictions, wait times to access the OPS and clients’ potential discomfort in accessing an OPS. Overall, the program has been well received by participants and provides learnings that can inform the implementation of other safe supply and harm reduction programs in Canada.

Program description

The hydromorphone tablet distribution program is located at the Molson OPS in the Downtown Eastside of Vancouver, Canada. The program was started in 2019 by the Portland Hotel Society (PHS), a housing and social service agency that operates the Molson OPS. The goal of this safe supply program is to provide a regulated alternative to illicit opioids to decrease the risk of overdose.

The Molson OPS is a provincially sanctioned harm reduction site. In addition to the hydromorphone distribution program, the Molson OPS offers a supervised consumption service, a drug-checking service (to determine what is present in a sample of drugs) and a service for injectable opioid agonist treatment (provided via an adjacent PHS clinic). The Molson OPS is considered an especially low-threshold model as it allows for the sharing of drugs and peer-assisted injection.

The program is delivered by the PHS primary care clinic, which is linked to the OPS. It serves people who are at high risk of fatal overdose and not currently enrolled in or interested in drug treatment programs such as opioid agonist therapy. Program participants access the program via the OPS, during operating hours (1:30 p.m. to 10:30 p.m. daily). The hydromorphone tablets are dispensed to program participants by nurses through a sliding window that connects the OPS to a nursing station on the other side. Participants are allowed to pause their involvement in the program at any time and return without having to be put back on the waitlist.

Participants are enrolled in the program through PHS clinic primary care physicians, who also visit the OPS twice per week. Participants are prescribed a weekly amount up to 80 milligrams per day. Participants can receive up to two eight-milligram tablets at a time and can come back for additional dosages up to five times per day, with a minimum one-hour waiting period in between.

To avoid diversion of tablets into the illicit market, participants are supervised while consuming the tablets onsite (whether they take them orally, snort them or inject them). However, since April 2020, “take-home” doses have been permitted under emergency COVID-19 pandemic prescribing guidelines in British Columbia. A small subset of participants receive an injectable, liquid hydromorphone formulation instead of tablets because of personal preference, including participants who have transitioned from an injectable opioid agonist treatment program.

As of February 2020, 69 participants were enrolled in the program.

Results

This study was a combination of interviews with 42 program participants and ethnographic observation at the OPS throughout 2019. The goal was to identify key barriers and facilitators to participant engagement with the hydromorphone tablet program.

The study found that key facilitators to program engagement included the following:

• Having access to a reliable, regular source of opioids enables participants to exert more control over their drug use, greatly reduces their fear of overdose and reduces their involvement in illicit behaviours to purchase drugs on the street.
• The program is located in the Molson OPS, a central, low-threshold, safe space where many participants were already accessing other harm reduction services.
• Participants are offered flexibility and choice in how to use the program, including varied consumption methods (e.g., oral, intranasal, injection) and flexibility in terms of when and how often to access the program.

The study found that key barriers to program engagement included the following:

• The limited operating hours of the program, particularly in the morning, when withdrawal may begin, meant many participants reverted to illicit opioid sources outside of program hours. (However, this issue may be less significant now that take-home doses are available).
• Co-location with the OPS meant potentially long wait times for people to access the program, especially during peak hours.
• The hourly-dose limits also meant participants could not receive their full daily dose without returning several times throughout the day. Very few participants received the maximum of five daily doses.
• The OPS, which participants must enter to access the program, may also be a triggering or uncomfortable environment for individuals who are attempting to reduce their drug use, or for those who did not use supervised consumption services before joining the program.
• There were complaints about lower potency and difficulty injecting a generic brand of the hydromorphone tablets that was used for a period when the brand-name hydromorphone tablets were unavailable.

What does this mean for service providers?

This study demonstrated a number of key facilitators and barriers for engaging users of the hydromorphone tablet distribution program. This information can be applied to the planning and delivery of other safe supply programs and, more generally, other low-threshold harm reduction programs. In particular, the co-location with other services and the flexibility of the program creates a lower threshold approach, especially for those who are most marginalized.

A number of barriers were also directly or indirectly tied to individual, social and structural factors such as housing, mobility and poverty. The intersection of these factors should be taken into account when designing and implementing other safe supply and overdose prevention programs.

Despite this, the study shows that safe supply programs can be a feasible public health intervention to address the overdose crisis. Although barriers exist, these can be addressed via considerations of how the program is delivered.  The authors noted that overall, the program was very well received among program participants. Taking into account high enrolment numbers and long waitlists, they expressed the need for scale-up of safe supply programs.

Related resources

keepSIX Supervised Consumption Service (CATIE)

Hepatitis C Treatment Program at Moss Park Consumption and Treatment Service (CATIE)

Harm reduction in action: Supervised consumption services and overdose prevention sites (CATIE)

References

1. Ivsins A, Boyd J, Mayer S et al. Barriers and facilitators to a novel low-barrier hydromorphone distribution program in Vancouver, Canada: a qualitative study. Drug and Alcohol Dependence. 2020 Sep 15: 108202.
2. Olding M, Ivsins A, Mayer S et al. A low-barrier and comprehensive community-based harm-reduction site in Vancouver, Canada. Public Health Practice. 2020; 110(6): 833-5.

Newfoundland and Labrador and Alberta, Canada
2020

A point-of-care (POC) HIV testing pilot program took place in two Canadian provinces, Newfoundland and Labrador and Alberta, to increase access to HIV testing and provide linkage to care. The program used pharmacists in four community pharmacies to provide HIV POC testing, including pre- and post-test counselling. Three-quarters of the people who were tested were at moderate to high risk for HIV and 27% were first-time testers. Pharmacies were found to be an acceptable venue for HIV POC testing by both pharmacists and clients; pharmacists felt prepared to provide testing and confident in doing so, and clients indicated that they felt comfortable receiving testing from pharmacists. Almost all clients (99%) who participated in a study of the pilot program indicated that HIV POC testing should be routinely offered in pharmacies.

Program description

Advisory committees were created in Alberta and Newfoundland to assist with the design of the pilot program. Committees consisted of a variety of stakeholders including public health officials, policy-makers, pharmacists, healthcare workers with experience providing care for people with HIV and individuals with lived experience.

The program provided free HIV POC testing using pharmacists in four community-based pharmacies in both urban and rural locations in Alberta and Newfoundland. The program was promoted through newspapers, social media (e.g., Grindr) and posters displayed in communities, as well as through organizations that serve populations that may be at risk for HIV. Clients could request an HIV POC test at one of the four sites by making an appointment or by visiting during scheduled drop-in testing hours.

At least one pharmacist at each pharmacy received training to participate in the program, which included training on consent and pre- and post-test counselling, as well as on how to administer the HIV POC test and interpret results. Pharmacists were provided with information on where to link clients if the HIV POC test was reactive, including support services in their area.

Participating pharmacies had a private room where clients and pharmacists met for testing and pre- and post-test counselling. The INSTI HIV-1/HIV-2 rapid antibody test (which requires a finger-prick blood sample) was used. Results were available within one minute; they were interpreted by the pharmacists and then shared with the client. Pharmacists completed pre- and post-test counselling, which included providing information on testing for other sexually transmitted and blood-borne infections.

If the test was reactive, the pharmacist provided the clients with a requisition for blood work to complete confirmatory tests, in addition to providing counselling and referral to additional supports. Confirmatory test results were sent to a designated physician or nurse practitioner, according to the linkage plan established in each province.

Results

A study of the pilot program (i.e., the APPROACH study) looked at the feasibility and acceptability of a pharmacist-provided HIV POC testing program and used a mixed-methods design. The study took place between February and September 2017. Clients were asked to complete two questionnaires (i.e., one before and one after testing) and were also invited to take part in a telephone semi-structured interview about their testing experience. Pharmacists’ perspectives were obtained through focus groups where they were asked to share information about the training and supports provided, as well as their thoughts on the scalability and sustainability of the program.

A total of 123 tests were conducted (10% in rural communities), with one reactive test. The person with the reactive test was linked to confirmatory testing and then successfully linked with the provincial HIV program within 72 hours of the HIV POC test. Additionally:

• Pharmacists spent an average of 30 minutes completing the testing process, including pre- and post-test counselling.
• 27% of clients indicated that this was their first HIV test. Of these, 69% were at moderate to high risk of undiagnosed HIV infection.
• 75% of participants were at moderate to very high risk of HIV infection¹ (47% self-identified as men who have sex with men, 7% had previously exchanged sex for money or drugs and 5% had a history of intravenous drug use).

Results from client questionnaires indicated that:

• clients felt comfortable getting tested at the pharmacy and had a high degree of confidence in the pharmacist’s ability to complete the test
• clients pursued pharmacy testing because of their ability to receive an immediate result and because testing took place in a private room
• 99% of clients indicated that HIV testing should be routinely offered through pharmacies
• 78% of clients indicated that they would pay for an HIV POC test at a pharmacy

Results from focus groups with pharmacists indicated that pharmacists felt that:

• the training provided prepared them well for the program
• a key element of the program was a clear linkage to care plan established by the advisory committee
• it would be important to have multiple pharmacists trained to perform the testing to increase accessibility
• lack of remuneration was a major challenge to the scale-up and sustainability of the program
• HIV POC testing was part of their professional role and identity

What does this mean for service providers?

Service providers should consider ways to move HIV POC testing into community locations where it might be possible for service providers to reach more people for testing and eliminate barriers experienced by potential testers (e.g., concerns over privacy and discretion). Pharmacies provide a way to normalize the testing experience in an environment that is familiar to people. Pharmacists who participated in this study indicated that providing HIV POC testing aligns with what they see as their professional role and identity.

Service providers looking to create a similar program should consider the workflow changes in the pharmacy required to implement it (e.g., support staff, documentation of results and follow- up plans). Consideration will also need to be given to the remuneration of pharmacists for providing the testing service, as well as the need to have adequate staffing so that a trained pharmacist can be available and provide greater flexibility for clients in terms of drop-in hours. Service providers should also ensure that an adequate linkage to care plan is in place for clients who have a reactive POC test. The quality assurance of the testing process and the standards of practice related to pharmacists’ ability to perform HIV POC testing in each province/territory should also be considered when developing a program.

Related resources

Task-shifting in HIV testing services

Rapid point-of-care HIV testing: a review of the evidence

Reference

Kelly DV, Kielly J, Hughes C et al. Expanding access to HIV testing through Canadian community pharmacies: findings from the APPROACH study. BMC Public Health. 2020;20:639.

1. HIV risk was based on the Denver HIV Risk Score using information gathered from the first participant questionnaire. A score of 30 points or higher indicated an increased risk of undiagnosed HIV and that someone should be offered routine HIV testing.

Ontario, Canada
2020

Black PRAISE (Pastors Raising Awareness and Insight of Stigma through Engagement) is an HIV-related knowledge and stigma awareness raising program focused on bringing information on HIV to Black congregations in Ontario, Canada. The program brought resources in the form of a booklet, a sermon and a short film to congregation members to strengthen congregants’ critical awareness of HIV-related issues in Black communities. In the quantitative component of a study that evaluated the program, Black PRAISE was associated with increased HIV knowledge and reduced HIV stigma among congregants who received the intervention.¹ In the qualitative component of the study, congregants expressed appreciation for Black PRAISE even though it challenged some of their beliefs and ideas about HIV and people who are affected.²

Program description¹

Black PRAISE aimed to increase HIV-related knowledge and decrease HIV-related stigma in Black churches. The program used a congregation-based approach and strived to prompt people to critically appraise their individual beliefs and knowledge related to HIV and HIV stigma. The program also aimed to build the capacity of churches to address critical health issues among Black communities.

A community-based participatory approach that engaged pastors and congregation members was used to develop Black PRAISE. The program took place in six Black churches in Ontario (Toronto, Mississauga, Ottawa) that were identified through community consultation. Pastors/leaders at each of the churches were men of Caribbean or African background.

User-friendly information related to HIV among Black communities was developed for the program, in the form of a booklet, a sermon and a short film. The components of the intervention were sequenced over time and addressed multiple issues related to stigma. The following resources addressed HIV-related knowledge and stigma to promote critical awareness:

• Booklet: A booklet addressed fear of HIV by conveying information about how HIV is transmitted and tested for and how it can be prevented in Black communities. The booklet also addressed issues of equity, justice and the social determinants of health and provided research data on how HIV disproportionately affects Black communities and specific information on HIV programs for Black communities in Ontario.
• Sermon: A sermon on love, compassion and social justice was delivered by pastors to their congregations. The sermon referenced biblical teachings related to reducing stigma and used anecdotes about experiences of stigma in church settings. Through these anecdotes, the sermon provided an audience for the voices of people living with HIV.
• Film: An 8-minute film featured Black Canadians discussing HIV stigma and how the church could help to reduce stigma. The film also illustrated how HIV stigma is layered with other dimensions of social oppression such as racism, sexism and heterosexism and showed the diversity of Black populations directly affected by HIV. The film was shown during church services.

The resources were distributed and/or presented to congregation members during their regular Saturday or Sunday service on an agreed schedule.

Results

A study of the program took place from October 2016 to March 2017 and evaluated changes in HIV-related knowledge and stigma at baseline, immediately after the intervention and at a 3-month follow-up using  surveys. Although the intervention was provided to anyone who attended the Saturday or Sunday service where the resources (i.e., booklet, sermon, film) were shared, only congregants who identified as African, Caribbean or Black were eligible to participate in the surveys. Knowledge of HIV and HIV stigma were assessed using separate validated tools.¹

A total of 173 study participants completed the baseline survey and at least one of the surveys after the intervention. Participants identified predominantly as Caribbean (54%) or Black (52%), female (74%), heterosexual (98%) and foreign born (68%). Additionally, 48% indicated that they had tested for HIV at least once and 95% indicated that they were HIV-negative or had never been diagnosed with HIV. Approximately 47% of participants indicated that they were exposed to one component of the intervention and 38% that they were exposed to all three components. The study investigators found that:¹

• There was a significant increase in HIV knowledge when baseline HIV knowledge was compared with HIV knowledge immediately after the intervention and at the 3-month follow-up.
• In an analysis of participants who reported high levels of stigma at baseline (i.e., people whose stigma scores exceeded the mean for the group), stigma decreased significantly after the intervention.
• Participants exposed to all three components of the intervention had a significant reduction in their stigma score compared with those exposed to just one or two components.

A qualitative study on the Black PRAISE program was completed between June and August 2017. It included 18 interviews with congregants and pastors to understand their experience with the program. Generally, participants’ experience with the program was positive. Some congregants shared that addressing stigma in a faith-based context led to a dilemma for them (i.e., viewing behaviours that may have exposed someone to HIV through the moral lens of their religion). The study suggested that successful interventions should support critical reflection of the underlying implicit assumptions and beliefs that motivate faith organizations, researchers and public health decision-makers. Moreover, this process of critical reflection should be ongoing to ensure longevity of similar interventions.²

What does this mean for service providers?

Service providers could consider inviting Black faith communities to play a more active role in their work, to engage African, Black and Caribbean populations in responding to HIV. Using a community-based participatory approach for program and resource development could help to ensure that resources are relevant to the populations that programs are targeting, in addition to helping elicit support from participating church leaders and congregants. Service providers should also consider using multiple resources that address a variety of issues that contribute to HIV stigma (e.g., individual beliefs, systemic conditions) when engaging community members in these critical awareness-building efforts. Phase 2 of Black PRAISE will engage a larger and more diverse group of Black churches across Ontario, using a more streamlined process that churches can use to administer the program.

Related resources

Operation Hairspray (CATIE)

Many Men, Many Voices (3MV) (CATIE)

Health Promotion Case Management Program (CATIE)

References

1. Husbands W, Kerr J, Calzavara L et al. Black PRAISE: engaging Black congregations to strengthen critical awareness of HIV affecting Black Canadian communities. Health Promotion International. 2020.  https://doi.org/10.1093/heapro/daaa057 
2. Husbands H, Nakamwa J, Tharao W et al. Love, judgement and HIV: congregants’ perspectives on an intervention for Black churches to promote critical awareness of HIV affecting Black Canadians. Journal of Racial and Ethnic Health Disparities. 2020. https://doi.org/10.1007/s40615-020-00808-5