Lethbridge, Alberta
2019

ARCHES (AIDS Outreach Community Harm Reduction Education Support) has opened North America’s first regulated supervised inhalation site (with safer smoking facilities) in Lethbridge, Alberta. The safer smoking facilities (SSFs) are part of a larger supervised consumption site (SCS) that offers all consumption options (i.e., injection, snorting and ingestion).

ARCHES is a harm reduction organization formed in 1986 that provides services for people living with HIV, hepatitis C and other chronic health conditions through programming such as community support, prevention, nursing, outreach and harm reduction supply distribution. ARCHES is well positioned to provide SCS services in Lethbridge. ARCHES built a case for opening SSFs in Lethbridge, which included (among other factors):

• the ability to medically supervise the consumption of substances, regardless of the method of consumption, to help prevent overdoses
• the ability to provide safer smoking supplies
• the ability to decrease the risk of blood-borne infection
• the ability to connect people who smoke drugs with a wide range of services, including harm reduction interventions and health education
• the importance of equitable access to healthcare services regardless of the way a substance is consumed
• the fact that people who smoke drugs will do so indoors if given the option

Program description

ARCHES received an exemption from Health Canada to offer supervised inhalation services, in addition to other supervised consumption services. A number of policies and procedures related to providing supervised inhalation had to be adopted; for instance, policies and procedures related to inhalation overdose intervention, emergency evacuation and workplace health and safety.

ARCHES worked with a heating, cooling and ventilation company, as well as an engineer, to design the SSFs. An important feature of the SSFs is their high-quality ventilation system, with an emergency smoke evacuation switch to quickly ventilate rooms if staff need to enter. Compliance with applicable smoking legislation was also required.

The safer inhalation services are promoted through community consultation, outreach programs and relationships with clients who have accessed other services at ARCHES. Clients also promote the service through word of mouth.

When clients enter the SCS they are asked which drugs they are planning to use and how they plan to use them. Staff then provide instructions to the client on the basis of their individual harm reduction needs. Separate injection and smoking facilities exist at the site and there are different SSFs for the consumption of different substances. Clients can use the SSFs with others using the same substances, as drug use is often a social event. Large demand has led to the SCS services being open 24/7 as of May 2018.

ARCHES consulted with existing clients about the development of the SSFs. They expressed interest in:

• having different smoking rooms for the consumption of different substances (to avoid cross-contamination)
• having the ability to inhale with others
• having a place for smoking that is monitored by staff

Results

The SCS opened on February 28, 2018, and 654 unique clients visited in the first four months. Characteristics of clients included the following:

• 38% were aged 20–29 years
• 35% were aged 30–39 years
• 58% were male
• 61% identified as Indigenous

Usage by inhalation accounted for 41% of client visits to the SCS in the first month of operation (March 2018). The number of client visits to the SSFs increased every month from March 2018 to June 2018 (967 in March, 1653 in April, 2184 in May and 3576 in June). Sixty percent of the total number of unique clients who used the SCS in March 2018 used the SSFs at least once in that month; this proportion remained fairly consistent from April 2018 to June 2018 (71% and 70%, respectively).

Substances used in the SSFs included methamphetamine (85% of recorded substances), opiates (5%) and crack (rock) (4%). There were 11 overdoses from inhalation in the SSFs’ first four months of operation (seven related to opioids and four to methamphetamine). Overdose from smoked drugs accounted for 4% of total overdoes at the SCS.

If clients are interested in moving from inhaling to injecting substances, they meet with a member of staff to discuss the potential risks. ARCHES has helped clients switch to inhaling opioids (rather than injecting them) by providing education and equipment to individuals interested in this alternative.

What does this mean for service providers?

The ARCHES SCS demonstrates how safer inhalation services can be offered within an SCS that provides a variety of drug consumption options. Part of the opportunity identified includes the ability of ARCHES to help clients transition from consumption methods that carry more risk (e.g., injection) to smoking practices that can carry lower risks of overdose and HIV and hepatitis C transmission.

ARCHES provides a unique model of supervised inhalation services that other SCSs in Canada may want to consider adopting through a Health Canada exemption. It also provides example of the detailed procedures and high-quality facilities required to provide safer inhalation services within the context of a larger SCS.

Related resources

Bringing STBBI testing to people who use drugs – Program Element

keepSIX Supervised Consumption Service – Case Study

Reference

Borque S, Pijl EM, Mason E et al. Supervised inhalation is an important part of supervised consumption services. Canadian Journal of Public Health. 2019;110:2010-215.

Seattle, USA
2019

The One-Step PrEP program provides access to pre-exposure prophylaxis (PrEP) through a pharmacist-managed PrEP clinic located in a community pharmacy. Use of the model resulted in high PrEP initiation rates.

Program description

This pharmacist-managed HIV PrEP clinic is located in Seattle, Washington, at an independent pharmacy. The One-Step PrEP team consisted of clinical pharmacists who initiated and managed PrEP distribution, as well as ancillary pharmacy staff who assisted with administrative and pharmacy tasks (e.g., processing prescriptions, scheduling appointments).

The program required a collaborative drug therapy agreement (CDTA) to establish a relationship between pharmacists and a medical director (an HIV specialist physician in this case). The CDTA allowed pharmacists to take on certain roles that are normally out of their scope of practice. Pharmacists received training through six self-directed modules that included information on Center for Disease Control and Prevention (CDC) PrEP guidelines, clinical trials, testing and treatment approaches, sexual history taking and risk-reduction counselling. Competency training occurred at regular intervals. Pharmacists also participated in ongoing training through case reviews.

Clients were referred to the program through local community-based agencies and local public health departments. A marketing plan was implemented to assist with recruitment. Once referred, clients received an initial consultation with a pharmacist where their medical and sexual histories were obtained and lab testing occurred as per the CDC guidelines. If clients were HIV negative and qualified for PrEP, they were offered PrEP for 30 days dispensed through the clinic (clients could also choose to have PrEP dispensed through a pharmacy of their choice) and were enrolled in the automatic refill option. Clients also received:

• counselling from the pharmacist on PrEP side effects and adherence
• referrals to mental health and substance use programs, as required
• coordination of insurance, as required
• 30-minute follow-up appointments with pharmacists in the clinic where all regular testing was performed including HIV and sexually transmitted infection (STI) testing at one month and then every three months (phone call, text message and email reminders were used)
• treatment for STIs when diagnosed
• counselling on behavioural risk reduction

Clients were referred to their primary care doctor or the medical director for concerns outside of the pharmacists’ scope of practice under the CDTA. If clients did not have a primary care physician, they were required to obtain one within one year of starting the program.

If clients presented to the PrEP program and had a preliminary HIV positive test they were immediately referred to the medical director.

Results

Between March 2015 and February 2018, 714 clients were evaluated in the pharmacist-managed PrEP clinic and 695 (97%) initiated PrEP. Of those who initiated PrEP:

• the mean age was approximately 35 years
• 99% were cisgender male
• the primary indication for PrEP was high-risk sexual behaviour in men who have sex with men
• 74% started the medication the same day

Three hundred and seventy-two clients remained active at the pharmacist-managed clinic as of February 2018; 11% of them had started PrEP use at the clinic, briefly discontinued it and then returned. Of the 323 clients who discontinued services and did not return, 34% transferred care and were linked to a primary care provider, 41% were lost to follow-up, 11% relocated and 12% had decreased perceived risk. There were no HIV seroconversions in clients who were engaged in the program. One client tested positive for HIV after having been lost to the program for three months.

STI testing was an important component of the program. Results show that 207 STIs were diagnosed in 135 clients, including 104 cases of chlamydia and 66 cases of gonorrhea. The majority of the chlamydia and gonorrhea cases were detected through rectal screening.

What does this mean for service providers?

The One-Step PrEP program demonstrates a way to increase PrEP access through use of a pharmacist-managed clinic, which could increase access for people who do not access health services in traditional settings or where PrEP access is limited. The scope of practice of pharmacists, including prescribing abilities, would need to be considered in other jurisdictions.

Delivery of this program in the pharmacist-managed clinic required the development of detailed testing procedures, and the pharmacists needed to obtain phlebotomy certification to perform the needed blood draws. The pharmacy also needed to have the ability to send tests to outside labs. Detailed procedures would need to be established in any pharmacy looking to create a similar program.

Related resources

Text Message Reminders – Case Study

Making the Links Program – Case Study

Reference

Tung EL, Thomas A, Eichner A et al. Implementation of a community pharmacy-based pre-exposure prophylaxis service: a novel model for pre-exposure prophylaxis care. Sexual Health. 2018;15:556-61.

Australia
2019

This program delivered hepatitis C treatment in prisons in Victoria, Australia. Nurses led treatment onsite in the prisons with support from specialists for complex, higher risk cases. This observational study followed hepatitis C treatment across 14 prisons for 13 months following the implementation of this program. The program treated 74% of eligible participants and had a high cure rate (96%) for those who completed treatment during their incarceration.

Program description

People entering prison are at higher risk of contracting hepatitis C because of the overrepresentation of at-risk populations that are incarcerated, including people who use drugs. Their time in prison further increases this risk because of the lack of safe injecting, tattooing and piercing equipment and a lack of access to health care services.

The nurse-led treatment program was conducted across 14 prisons. Participants were offered “opt-in” screening for hepatitis C upon entering prison. If a participant tested positive for hepatitis C during this screening or self-reported a previous diagnosis, they met in-person with a hepatitis C program nurse at the prison. The nurse performed an initial assessment, including:

• a questionnaire about risk behaviours for hepatitis C
• a test to assess liver injury
• additional testing for hepatitis C, hepatitis B and HIV
• recording of other health issues, including psychiatric illness

After this assessment, eligible participants enrolled in the program to begin treatment. To be eligible for treatment, participants were required to have a long enough sentence duration to complete hepatitis C treatment (between eight and 24 weeks). Those with shorter sentences were ineligible, but they were referred to a healthcare service for treatment upon release into the community.

The program was staffed by:

• two full-time nurses
• three part-time hepatologists (who were accessible by telemedicine)
• a part-time pharmacist
• a part-time pharmacist technician

Treatment and care for participants who had less complex cases and no liver disease was led by a program nurse, with paper-based consultation with a physician for medication prescriptions. Participants who had more complex cases, including those with cirrhosis, received additional assessment and oversight from a hepatologist either in-person or through telemedicine appointments. Participants with cirrhosis enrolled in a monitoring program for liver disease.

The central prison hospital pharmacy couriered medications to each prison. Medication delivery moved with participants if they transferred between facilities during their treatment course. If they were released early, they were given their remaining medication to complete treatment in the community.

The study measured the success of treatment with blood tests performed 12 weeks after treatment ended, which showed whether the participant had been cured.

Results

This observational study followed an initial group of 416 individuals who began treatment as part of the program. Of this group, 103 individuals were lost to follow-up because they were released from prison or they did not complete treatment. Of the 313 individuals who completed treatment and were tested at 12 weeks, 301 (96%) were cured. This program demonstrates that a decentralized model of nurse-led treatment was highly effective in increasing hepatitis C treatment access in prisons, with high rates of cure.

Of the participants assessed, 82% were considered to have less complex needs, with no liver disease, and they had their treatment led by a program nurse. This suggests that in a majority of cases, hepatitis C treatment in prisons can be overseen by nursing staff.

What does this mean for service providers?

To achieve elimination of hepatitis C, people in prison represent a priority population that must be addressed. Increasing treatment access is a major pillar of a Canadian elimination strategy. This program is an example of a nurse-led, decentralized model that can effectively engage a large number of people in treatment with very high cure rates. 

This program demonstrates that hepatitis C treatment with direct-acting antiviral therapies has become reliable and straightforward. In many cases there is no need for specialized medical staff, and programs can be delivered by nurses working in a decentralized fashion in individual prison facilities. This can lessen the need for specialized healthcare staff or for prisoners to be transported to centralized healthcare facilities. In cases where more specialized care is needed, technology like telemedicine can help remotely link hepatologists or other specialists to patients.

Related resources

Blueprint to inform hepatitis C elimination efforts in Canada (CanHepC)

Blueprint to Inform Hepatitis C Elimination Efforts in Canada: What do service providers need to know? (CATIE)

Micro-elimination of hepatitis C: A pathway to achieve national elimination goals (CATIE)

Reference

Papaluca T, Mcdonald L, Craigie A, et al. Outcomes of treatment for hepatitis C in prisoners using a nurse-led, statewide model of. Journal of Hepatology. 2019;70:839–46.

2019

Overview

Nine Circles Community Health Centre (Nine Circles) has integrated a registered nurse (RN) within a harm reduction supply distribution room for one hour per day, four days a week. A health educator, known as a community facilitator, distributes requested drug supplies and asks clients if they are interested in testing for sexually transmitted and blood-borne infections (STBBIs). If clients are interested, the community facilitator refers them directly to an RN if one is present or notifies clients of testing hours. The goal of the initiative is to increase testing for STBBIs including HIV, hepatitis C and syphilis, and gonorrhea for people who inject drugs. Testing options include blood and urine samples, rectal and throat swabs and point-of-care tests (i.e., rapid HIV tests). A secondary goal of the program is to connect clients to the primary care services on site if they have no current provider. Nine Circles delivers comprehensive primary care, social support, education and prevention services creating healthier communities for Manitobans.

Why was the program developed?

Nine Circles was part of a project that explored STBBI testing challenges and opportunities in Winnipeg through the Manitoba HIV Collective Impact Network, which is working to transform the landscape of HIV in Manitoba through stigma reduction and prevention, as well as testing and linkage initiatives. The project involved reviewing who is currently using testing services, developing opportunities for collaboration to connect with hard-to-reach populations, and sharing tools and best practices related to completing sexual health assessments. The work also included a client survey, a forum for educators and clinicians who do HIV/STBBI testing, and a final report, which outlined results of this work and made recommendations on next steps.

On the basis of the recommendations of the report, Nine Circles recognized that clients who were accessing their low-threshold harm reduction supply distribution services were not accessing the other health services offered at the community health centre (e.g., primary care, STBBI testing). In response to this identified need, an RN from the health clinic was brought into the harm reduction program four days a week for one hour each day to provide testing and primary care referrals to people who use drugs. This program started on July 3, 2018.

Tammy Reimer, Director of Allied Care and Health Promotion at Nine Circles, explains:

“…we were still trying to find ways for those who were not accessing care to come through our door and fit into our system (e.g., make an appointment and return, wait at the drop in). The challenge was to think about what it would look like for us to walk out the door to the client. What we needed to do was utilize the space/program where staff had already developed a level of trust and to build on this by offering testing and subsequently primary care.”

How does it work?

When a client visits the harm reduction program at Nine Circles they can request drug use supplies from the community facilitator, who is a member of the health education team. The community facilitator, through their interactions with the client, asks if the client is interested in STBBI testing. If this occurs Monday, Tuesday, Thursday or Friday between 1:00 and 2:00 pm the community facilitator directly connects the client with an RN if the client wishes to be tested. If this happens outside these hours the client is encouraged to return during testing hours for their test. 

An RN initially connects with a client in the supply distribution room and testing is completed in an exam room, office space or the supply distribution room, although testing in the supply distribution room is less frequent. The RN shares testing options with clients that include point-of-care tests, swabs, and urine and blood sampling, and clients identify which STBBI testing they are interested in (e.g., chlamydia, gonorrhea, syphilis, HIV, hepatitis C), as well as the type of tests that they would like. The client provides verbal consent and the RN proceeds to collect the specimens for analysis. The role of the RN also includes getting to know clients and building trust.

Clients receive results of point-of-care tests on the spot. For other types of testing, the client can provide a contact number or email and the RN will follow up with them in one or two weeks if any of the test results are positive. If the client does not have contact information, they are encouraged to check back with the community facilitator in one or two weeks for test results or make an appointment at the health centre.

In terms of linking clients to primary care, the nurse asks clients about whether they have a primary care provider, and asks those who do not whether they would like to be connected to one. Depending on where clients are at, they may be interested in being linked to a provider or may prefer to see the sexually transmitted infection (STI) nurse if treatment for an STI is required. Under a directive (allows specific procedures to be delegated to and conducted by another trained health professional), nurses can currently provide treatment for STIs at Nine Circles and in the future they will be able to so independently after completing an advanced prescriber course (probably by 2020).

The RNs have documentation requirements related to this program, which requires up to approximately 30 additional minutes/day. The RN creates a chart for the client (with their permission) and collects data such as whether the client is a first-time tester and the test results and then collects information about any repeat testing that the client receives. The initiative does not require any additional funds to implement.

What has the program accomplished?

An evaluation of the first 12 weeks of the program indicates that a nurse was available in the supply distribution room for a total of 44 hours (i.e., one hour per day for four days a week). In this time, 17 people were open to connecting with a nurse about testing, with 15 of those individuals consenting to testing. Out of the 15 clients who consented to testing:

• 40% (six) were first-time testers (i.e., a person who has not previously been tested for an STBBI)
• 40% (six) tested positive for one or more STBBIs (three people had multiple infections)
• 80% (12) consented to HIV, hepatitis C and syphilis testing
• 33% (five) opted for point-of-care testing for HIV
• 33% (five) completed follow-up by either returning for a booked appointment or following-up with their primary care provider, with four people agreeing to receive a referral to a primary health care provider at Nine Circles
• There were no reactive tests for HIV or hepatitis C

What are the challenges and lessons learned?

The program brings STBBI testing to clients in a low-barrier setting where trust can be established between staff and service users. However, it can be challenging to connect clients to follow-up and treatment services after they receive an STBBI diagnosis, as some clients follow through and others do not.

This program is still in its early stages and currently the nurse is only in the supply distribution room for one hour per day, so it can be difficult to reconnect with clients because of the nurse’s limited availability. As the program continues to operate and learning continues, changes can be made to the approaches used.

The best advice from Kim Witges, Clinical Director at Nine Circles:

“Engage your staff and let them take the lead on what needs to happen; it may fail or succeed, but let it unfold. Be willing to not have all of the answers prior to starting, but be keen to figure it out along the way.”

Contact

Kim Witges, Clinical Director
Nine Circles Community Health Centre
705 Broadway
Winnipeg, MB
R3G 0X2
Email: kwitges@ninecircles.ca