What is the Program?
The Anonymous HIV Testing Program in London, Ontario, provides HIV prevention, testing and counselling services to at-risk populations on an outreach basis in and around the city. The program, coordinated by the London InterCommunity Health Centre’s Options Clinic, is staffed by two HIV counsellors. HIV testing and counselling services are offered in various locations across London and in the surrounding counties of Perth, Lambton, Huron, Elgin, Middlesex and Oxford. Options Clinic is one of 50 sites across Ontario that offers anonymous HIV testing.
The program has offered access to HIV prevention, testing and counselling services since 1993. In 2007, the Anonymous HIV Testing Program started providing rapid HIV testing using the INSTI HIV-1/HIV-2 rapid antibody test in addition to standard blood-draw testing. However, the counsellors have performed only a few tests using the standard blood test since the rapid test was introduced.
Options Clinic leverages the long-standing relationships that other community-based organizations have with their clients to offer low-barrier HIV prevention, testing and counselling services in venues that are more comfortable and more accessible for clients than Options Clinic’s fixed site. Through its partnerships with these organizations, Options Clinic has developed its own reputation among populations at risk for HIV.
Why Was the Program Developed?
Options Clinic’s outreach HIV prevention, testing and counselling services were developed to increase HIV prevention, testing and diagnosis rates in London, Ontario, and surrounding areas among at-risk populations. Because at-risk populations—gay men, youth, Aboriginal people, people who use injection drugs and people from countries where HIV is endemic—are sometimes also less likely to access services in clinical settings than the general population, Options Clinic developed a series of outreach clinics to meet clients in community-based organizations that they were already accessing for services. These include a youth drop-in centre, a bathhouse, a needle exchange site and clinics specifically for university students and Aboriginal people. The goal was to reduce barriers between HIV testing and clients in the community.
The Anonymous HIV Testing Program was also developed to increase the reach of anonymous HIV testing in and around London. Clients who access anonymous testing do not identify themselves, do not show identification and will not have their tests linked to their names. This is significant for people who want to know their HIV status but wish to remain unknown to the healthcare provider and the healthcare system.
How Does the Program Work?
The Anonymous HIV Testing Program at Options Clinic offers services in various venues that work with populations at higher risk for HIV infection. On a weekly, biweekly, monthly or quarterly basis, depending on the venue, a counsellor offers on-site HIV prevention, testing and counselling services to clients who prefer to receive information or take an HIV test anonymously on a drop-in basis in a community-based organization rather than at a clinic.
Options Clinic has spent 20 years developing strong partnerships with area bathhouses, universities, AIDS service organizations, youth centres and service providers for Aboriginal people to be able to provide HIV services in culturally appropriate spaces.
Counsellors
Options Clinic’s outreach clinics are staffed by two counsellors, who are trained to offer both rapid and standard blood-draw testing. One of the HIV counsellors also serves as the program’s coordinator. The coordinator is responsible for developing and maintaining partnerships with community-based organizations, compiling statistics, reporting to the program’s funder and ordering any supplies the program needs.
Partnership building
Options Clinic has been successful at reaching out to diverse populations because its staff practise with an intense focus on cultural competency. They have leveraged the strong links that their partners (e.g., a needle exchange site, a youth centre, a bathhouse) have made with their clients and used those relationships to build their own reputation as sensitive, competent and discreet counsellors.
The program coordinator identifies agencies in the community that serve at-risk populations and approaches them to offer HIV testing services. Typically, the coordinator makes this approach through presentations on HIV, the impact of HIV on the population the agency serves, and the benefit of point-of-care testing in making HIV testing more accessible. The coordinator focuses on building a strong relationship with a contact (the program coordinator, manager or executive director) in each organization and works with that person to demonstrate how offering HIV prevention, testing and counselling services in their organization would be beneficial for their clients.
To reach out to Aboriginal people, Options Clinic partnered with the Ontario Aboriginal HIV/AIDS Strategy (OAHAS), Ontario’s Aboriginal AIDS service organization. This partnership provided Options Clinic, which does not specialize in healthcare for Aboriginal people, legitimacy with this population. It demonstrated to many other Aboriginal organizations that Options Clinic could offer HIV prevention, testing and counselling services appropriately to Aboriginal people. This partnership expanded both agencies’ capacity to test and to provide culturally specific pre- and post-test counselling for members of Aboriginal communities.
Partnership agreement
Each of Options Clinic’s partners signs a partnership agreement that outlines Options Clinic’s responsibilities and the responsibilities of the local organization (please see the Program Materials section of the case study for a sample partnership agreement). The partnership agreement also outlines what happens when counsellors are not available to provide testing in outreach clinics (periods when the counsellor is ill, on vacation or on extended leave): the hours of operation of the outreach clinics may be reduced or the clinics may be temporarily suspended.
The Options Clinic’s responsibilities, according to the partnership agreement, are to provide pre- and post-test counselling, provide and perform the rapid tests and any venous blood draws needed, and store blood specimens until they are collected by LifeLabs Medical Laboratory Services for analysis. The Options Clinic also commits to collecting necessary data for the Ministry of Health and Long-term Care and sharing those data with the local organization when it is requested.
The program is funded through the Ontario Ministry of Health and Long-term Care’s AIDS Bureau, which provides the funds directly to Options Clinic. Partnering organizations typically do not incur any costs for hosting HIV outreach clinics. Partner organizations commit to providing a private room with a table and two chairs that can serve as a clinical space and to promoting the clinic to their clients.
Where outreach takes place
Options Clinic has been strategic in partnering with organizations that have long-established relationships with populations at risk for HIV infection and who may be in need of added opportunities to receive HIV prevention, testing and counselling services in low-barrier spaces. All HIV services are offered on a drop-in and anonymous basis in an effort to make them as accessible as possible.
What makes Options Clinic’s outreach clinics unique is the variety of venues and populations the counsellors reach at least once a month with HIV prevention, testing and counselling services.
At a bathhouse
A disproportionate number of new HIV infections continue to be in gay men and other men who have sex with men; in Canada 50 percent of new infections are in gay men and it is important that HIV services be widely available to this population.
Since 1993, Options Clinic has offered HIV prevention, testing and counselling services to gay men and other men who have sex with men at the Central Spa in London. A clinic is set up twice a week in a private room off the main cruising area.
In September 2013, Options Clinic started offering syphilis testing in addition to HIV testing and counselling at the Central Spa because gay men and other men who have sex with men are disproportionately affected by syphilis in Ontario. Providing syphilis testing at the bathhouse in tandem with testing for HIV reduces barriers for some clients.
At London Pride
Options Clinic has offered HIV prevention, testing and counselling services to participants at London Pride since 2008. Staff have observed that providing testing on site at Pride, rather than in a location that is nearby but off site, has increased the number of tests performed at the festival.
In a youth centre
The Options Clinic has provided HIV services to street-involved youth at Youth Opportunities Unlimited’s Youth Action Centre since 2001. An HIV counsellor is present, in a private room off the main meeting area, for two hours every second week. Setting up a clinic in this venue has meant that youth who may distrust people in authority and who may have difficulty keeping appointments can access HIV prevention, testing and counselling services on a drop-in basis in a non-threatening environment.
At a needle exchange site
Options Clinic also offers HIV services at Counterpoint, a needle exchange program operated by Regional HIV/AIDS Connection, London’s AIDS service organization. Testing is offered in a closed room in Counterpoint’s offices, as a way to increase HIV testing among people who use injection drugs. Counterpoint distributed 2.3 million needles in 2012-2013, an indication that there is a significant population of people injecting drugs in the city who, despite having access to clean needles and other harm reduction supplies, may need to have frequent HIV tests.
The outreach clinic at Counterpoint is set up every two weeks. It allows people who use injection drugs, who already come to Counterpoint regularly to pick up new drug use equipment, to get an HIV test on site at regular intervals, without having to access a different location for testing.
At a university
In 2008, Western University asked Options Clinic to offer HIV prevention, testing and counselling services to students on campus every two weeks. This outreach clinic has experienced inconsistent testing numbers. The success of the clinic depends on the efforts of the vice-president of student services, as this student representative is responsible for promoting the clinic, booking a room for the clinic and booking appointments. A new representative is elected each year, and when the incumbent does not prioritize the clinic, numbers drop.
Despite the challenges, Western University’s clinic has been successful at reaching young gay men and students from the African and Caribbean communities who may not be comfortable accessing sexual health services at Options Clinic’s main site.
Among Aboriginal communities
Whenever appropriate, Options Clinic partners with the Ontario Aboriginal HIV/AIDS Strategy (OAHAS) to offer HIV prevention, testing and counselling services to Aboriginal communities. The OAHAS regional outreach worker for Western Ontario is certified to offer rapid, point-of-care testing. The partnership includes providing testing clinics in Aboriginal organizations and at London Pride, where in 2013, 25 percent of all people tested identified as Aboriginal.
At the beginning of this partnership, Options Clinic counsellors set up biweekly clinics at the Southwest Ontario Aboriginal Health Access Centre, an Aboriginal-centered health centre in London that also provides healthcare on two reserves. The Anonymous HIV Testing Program’s coordinator also leveraged partnerships with N’Amerind Friendship Centre and At^Lohsa Native Family Healing Services to offer presentations on HIV to the clients of these organizations. The presentations are typically paired with lunch and offer Aboriginal people the opportunity to learn more about how HIV affects their community before they commit to receiving a test. HIV testing and counselling services are offered on site immediately after presentations.
The coordinator found that Options Clinic performed fewer tests at Southwest Ontario Aboriginal Health Access Centre than when the counsellors presented an HIV workshop to organizations that serve Aboriginal peoples. It is not clear yet why this was the case, but in response to this anecdotal evidence, Options Clinic has ended its biweekly testing clinics at Southwest Ontario Aboriginal Health Access Centre and is instead offering quarterly HIV testing presentations and testing services to Aboriginal organizations, including the health access centre, N’Amerind and At^Lohsa. Counsellors have performed more tests among Aboriginal people using this method.
Among rural communities
Options Clinic partnered with Regional HIV/AIDS Connection in 2007 to offer anonymous HIV testing in rural communities in southwest Ontario. The decision to expand testing to rural areas came from a recommendation made through a consultation process that was part of the Ontario provincial strategy on HIV/AIDS.
Options Clinic and Regional HIV/AIDS Connection held a pilot clinic in a community venue in Stratford to test the partnership between the organizations and the community venue and to evaluate the uptake of anonymous testing in rural communities. This initial clinic was so successful that Options Clinic and Regional HIV/AIDS Connection have worked together since to offer outreach testing in rural communities six times a year.
In this partnership, the regional coordinator from Regional HIV/AIDS Connection uses their contacts with community health centres, community clinics and other community-based organizations in rural communities in the counties of Perth, Lambton, Huron, Elgin, Middlesex and Oxford to set up days and times for outreach clinics.
Annual outreach clinics are set up in communities where good turnout has been observed in previous years. If turnout has been low in a particular community, the regional coordinator seeks new organizations in different communities and sets up clinics there instead. In 2013, over six clinics, 13 tests were performed. The Anonymous HIV Testing Program’s coordinator has observed that the clinics are reaching people at risk for HIV infection, including gay men, other men who have sex with men, and long-distance truck drivers.
Incentives
In the bathhouse, the Youth Action Centre and at organizations serving Aboriginal people, Options Clinic and their partners offer incentives for testing. The incentives are small, typically gift cards worth less than $10 (and locker passes at the bathhouse), and are seen as a way to engage clients who may be hesitant to test.
The incentives are not perceived by providers as coercive; rather, they are seen as an encouragement for making the difficult decision to test. Incentives are also offered to encourage people who may need frequent repeat testing (men at the bathhouse, for instance) to continue to test. It has been noted that when incentives are depleted at the Youth Action Centre, fewer tests are performed, suggesting that the incentives are one reason some youth seek HIV testing and counselling.
It has not been necessary to provide incentives for testing in rural outreach clinics; the ability to get an anonymous test may be incentive enough for rural dwellers. It has also not been necessary at Pride, at Western University or at Counterpoint, where clients have generally been responsive to testing.
How outreach clinics operate
All but one of the outreach clinics operate on a drop-in basis. This allows clients who may have difficulty making and keeping appointments to access testing when it is right for them. At each venue someone on staff is available to let clients know that anonymous HIV testing and counselling is available.
The exception is Western University where students are expected to make appointments to see a counsellor. This requirement was established because of the size of the university’s student population and the unlikelihood that a person who wanted to test would stumble upon the clinic.
Most partner organizations serve clients who may distrust healthcare providers. As a result, counsellors must build trust with clients. At each site, they do this by patiently engaging with individuals, often by providing prevention services and education as the first step toward increasing people’s readiness to have an HIV test.
All of the outreach testing clinics follow the Ontario government’s Guidelines for HIV Testing and Counselling, which provide HIV counsellors with a framework on how to conduct their work appropriately. The guidelines explain what should be covered during pre- and post-test counselling, provide a counselling checklist, outline safer sex and risk reduction information and include an appendix with additional counselling information for at-risk populations including gay men, Aboriginal peoples, clients from the African, Caribbean and Black communities, and youth.
A typical testing appointment takes about 20 minutes. The counsellor provides pre-test counselling, assesses risk and explains how the test works. The counsellor then performs a rapid test using an INSTI HIV-1/HIV-2 rapid antibody test and reads the results. When tests are reactive (preliminary positive) counsellors offer to draw blood for confirmatory testing. Most clients accept confirmatory testing, although a few decline. These clients are asked to follow up with their primary healthcare provider for confirmatory testing and linkage to specialized HIV care.
The Options Clinic counsellors diagnose about two clients with HIV each year through their outreach clinics. This is consistent with the positivity rate (0.7 percent) of many anonymous clinics in Ontario.
Linkage to care
Clients can receive the results of confirmatory tests either by attending a subsequent outreach clinic or by visiting Options Clinic’s fixed site. Counsellors can facilitate linkage to care at the Infectious Diseases Care Program at St. Joseph’s Health Care (a hospital in London) or through the London InterCommunity Health Centre. Clients are also referred to Regional HIV/AIDS Connection for psychosocial support.
Required Resources
- Coordinator. Provides administrative support for the program, maintains connections with outreach sites and provides HIV prevention, testing and counselling services.
- HIV counsellor. Provides HIV prevention, testing and counselling services.
- Strong network of collaborators and partners in the community to host outreach testing clinics at bathhouses, youth centres, Aboriginal health centres and other community-based organizations.
- Building trust among Aboriginal service providers. Building a strong partnership with service providers whose main clients are Aboriginal people was initially a challenge for Options Clinic. Options Clinic partnered with the Ontario Aboriginal HIV/AIDS Strategy to overcome this barrier. In partnering with Options Clinic, the Ontario Aboriginal HIV/AIDS Strategy vouched for the ability of Options Clinic to offer culturally appropriate HIV services to Aboriginal people.
- Changing contacts at the university. The vice-president of student services at Western University is the primary contact for Options Clinic at the university. This elected person changes yearly, which means that Options Clinic must build a relationship with a new student representative each year. This has resulted in inconsistent testing numbers at the university, since some vice-presidents may not see the HIV testing clinic as a priority and will not devote as much time to promoting it as others.
Evaluation
The Options Clinic outreach counsellors keep a record of the number of clients tested and the number of positive test results and compile demographic information for all clients who are tested. In 2013, 945 people sought testing from Options Clinic, 296 of those on outreach. In a typical year, about two individuals with HIV are diagnosed through outreach clinics. This is consistent with the positivity rate (0.7 percent) of many anonymous clinics in Ontario.
Options Clinic also measures its success through the relationships it builds with clients and other community-based organizations. Providing anonymous HIV testing on an outreach basis increases the visibility of Options Clinic in the community. This visibility in a variety of venues has not only increased access to HIV testing in the community but has also increased the number of tests performed among certain populations at Options Clinic’s fixed site.
The most noticeable effect of the increased visibility of Options Clinic has been the increased number of Aboriginal people seeking testing at Options Clinic. In 2010, about four percent of people tested at the clinic self-identified as Aboriginal. In 2013, that number jumped to eight percent. Counsellors credit this to their continuous presence and engagement with organizations and clinics serving the Aboriginal community.
A similar trend has been observed among people who use injection drugs. Between 2011 and 2013, the percentage of people who use injection drugs accessing Options Clinic’s fixed site rose from seven percent to 12 percent.
The visibility of Options Clinic at Western University, where many of the outreach clinic’s clients are of African or Caribbean descent, has increased the number of people from those communities who are accessing testing at Options Clinic’s fixed site even though the clinic does not do specific outreach to these communities. The program coordinator attributes the increase in the number of students from these communities visiting the fixed site to word of mouth.
- Provide testing in partnership. Options Clinic partners with local organizations that serve priority populations (gay men, youth, people who inject drugs, Aboriginal people) and leverages their good reputation in the community to provide testing. Forging relationships with well-respected community agencies serving priority populations and then maintaining testing clinics at those agencies has contributed to improved trust in Options Clinic.
- Provide testing that is convenient. For outreach testing to be effective, counsellors must see clients when and where they want to test. Having various sites allows Options Clinic to provide low-barrier service to as many priority populations in London as possible.
- Adapt testing to each population. Some populations are more likely to test when incentives are offered (gay men and youth, for example) and in these instances Options Clinic offers modest incentives to clients who test. Options Clinic has also adapted the way it offers testing to Aboriginal communities by organizing presentations on HIV and the rapid test for groups of clients and then offering testing privately immediately afterward.
- Outreach testing boosts fixed location testing. Options Clinic’s reputation for providing non-judgemental HIV prevention, testing and counselling services to at-risk communities has been cemented as a result of the outreach clinics. In the last year, work among Aboriginal communities, with people who use injection drugs and with members of the African, Caribbean and Black communities has contributed to an increased number of tests at Options Clinic’s fixed location for those populations.
Program Materials
- Community partner agreement to provide anonymous HIV testing services
- Options Clinic HIV testing questionnaire
- Options Clinic HIV counselling flow sheet
Contact Information
Lyn Pierre-Pitman
Coordinator, HIV Testing Services
Options Clinic, London InterCommunity Health Centre
659 Dundas Street
London, ON N5W 2Z1
519.660.0874 ext. 253
lpierrepitman@lihc.on.ca