Providing community pop-up clinics in Vancouver’s Downtown Eastside…
The Vancouver Infectious Diseases Centre (VIDC) is a non-profit organization that has been providing multidisciplinary care to HIV and HCV patients since 2000. It works to engage with and provide tailored care to marginalized communities and, ultimately, to promote long-term patient engagement as an agent for social change for those communities.
We recently sat down with Dr. Brian Conway at the VIDC to find out more.
Tell us more about your project. Where does this idea come from? Who are your target populations?
UNAIDS, in collaboration with the World Health Organization, has set very ambitious goals for the suppression of HIV infections across the globe over the next several years. Globally, we did not reach the goals for the 2020 targets, but we have a key opportunity to meet those set forth for 2030 and ending the HIV/AIDS epidemic by 2030 where 95 per cent of people living with HIV know their status. In the work that we do, it became clear that certain populations, such as people living with HIV and vulnerable populations who live in the inner city, particularly injection drug users, are nowhere near meeting that goal. In fact, preliminary surveys indicated to us that perhaps half or less of HIV-infected injection drug users were responding in an optimal way to antiretroviral therapy. So, I think it becomes important to identify why that is, and to design specific strategies to engage these individuals in care, particularly in HIV care, and make it so that they will benefit from the promise of highly effective antiretroviral therapy going forward. Thanks to ViiV Healthcare, we secured funding to implement our project, which focuses on helping these targeted populations with specific strategies that address their needs, such as peer work and community-based initiatives and support.
Education is a key component of your project. What are the main topics you cover in your educational sessions?
We had a previous project with ViiV Healthcare that was very successful. That project was really aimed at educating people about how you get HIV, the behaviours that transmit HIV and how you can get tested very quickly. I think this can be reinforced yet again because there are some people out there who are undiagnosed. The key component of teaching, that would be mixed in with this multidisciplinary intervention, is to tell people that although HIV is not curable, it is controllable and that the treatments have become much simpler. It is also important to remind them that the treatments are available, free, and that we can coordinate any treatment they want to their convenience. For example, we can get it sent to a pharmacy that they normally go to, or we can provide it to their place of residence on a weekly basis. We will be there to help support them. They’ll have blood tests done, etc.
What we’re currently doing is consolidating the education that we did in the previous project about HIV transmission and testing, and adding the component of treatment and its long-term benefits. Moreover, we educate about other topics such as hepatitis C, COVID-19 and other wellness issues. So, they are used to this educational intervention, and adding this HIV intervention in the context of the knowledge we have now – i.e., half of HIV-infected injection drug users being unsuppressed – is important.
There are factors that contribute to the disengagement of people living with HIV from the traditional healthcare system. How can a holistic approach effectively meet the HIV care and treatment needs of people living with HIV?
The healthcare system does not currently meet the needs of patients. In many cases, these are individuals that have addiction-related needs, social needs, psychological needs, in addition to their very important medical needs. Unless a strategy is put in place to meet the needs that they prioritize at any given point, it will become difficult to engage them to take antiretroviral therapy in a reliable manner and have the virologic suppression that we mean to achieve.
I think a holistic, patient-centred approach is the best path forward for vulnerable populations. As professionals or individuals working in the community, we need to constantly be reminded that of these populations’ 10 highest priorities on a given day, HIV is probably number nine or 10. So we’re not going to make any gains if we try to convince them that HIV is the most important thing to them in their lives. Nevertheless, the holistic approach puts the patient at the middle of the intervention. It makes certain that the top 10 priorities to get patients that day are being addressed, and in establishing partnerships we can quickly get to a point where HIV care becomes relevant and essential to them. Convincing these populations is a process and it can only be accomplished by a holistic approach. That’s why our first move was to create engagement and to make it multidisciplinary, addressing all the needs of vulnerable populations. Finally, we have to make sure that it’s durable.
What are some of the mechanisms in place to keep these people engaged?
Since HIV is not a curable disease, they need to stay on treatment for years. This isn’t a one-time intervention. This needs to be a durable and structural process that they believe in and that they will buy into. This is a project that needs to be community based. We have to go to them, as they are not coming to us. Second, we must have on the team people who are able to meet all the needs these populations may require. In many cases, the physician – the medical doctor – is almost trivial in the sense that we write prescriptions that will meet acute medical needs that others can’t address. This is our expertise. However, the relationship, the bond, is done by support staff, peers and nurses. They are much more flexible in their mandate, in the time that they have. They can be directed to meet the needs of individuals on an ongoing basis as they vary. And that’s even more important with COVID now being in the background. HIV infection may not have been the highest priority in our society and is now pushed further down the list of priorities.
How do community outreach initiatives remove barriers to accessing care, treatment education and support?
It really is through building relationships and partnerships that you succeed in removing these barriers. The human aspect is instrumental. People working at the grassroots level build these relationships and then they act on them on an ongoing basis. It is valuable. People think it’s hard to combine the work and rigor of health professionals with community-based initiatives, but this interaction is entirely possible.
At the operational level, what you need first and foremost is to use the grassroots. You can’t expect a project to succeed if you don’t have a strong community outreach. It’s all about linking up with places where people live: the single-room-occupancy buildings, talking to the managers, figuring out what’s a good time to be there with whatever the needs of the people happen to be according to the manager, sending in people. Peer workers are very important! Support staff and nurses. Where the doctor fits in is to supervise specific events, to provide that important medical opinion on the spot when it’s needed, and to sort of supervise and support the program.
It’s a team approach on our side, it’s a team approach on the side of the community. I think that it is because we have spent time building these relationships that we’re able to act in the way we do in the current project, and help people getting efficient care and treatment.
To what extent can peer work be considered a complementary approach in some cases to the traditional healthcare system? What are some of the benefits of providing peer support?
In many cases, the public healthcare system is really solid, but it’s a bit top-down in the sense that they establish policies, they establish programs. If the program doesn’t work or if it doesn’t meet the needs of the population, they really get into trouble very fast, as they can’t be flexible and they can’t change. Second, we have had many misses when conducting grassroots projects over the past 20 years: things that we’ve tried that we thought would work but didn’t work because they weren’t based enough on the community, because there weren’t enough interactions with the community. Once trusted relationships are built, success is still not guaranteed. But we have a process that has worked for us in the past and we are tweaking it to address issues in a very targeted manner. If we don’t succeed, we will have the ability to understand, hopefully at a very granular level – at a very targeted level – what didn’t work and what we need to change. This is something the public health system does not have, yet it makes public policy all the more effective.
To summarize, we believe in three pillars to make the patient-centred holistic approach a reality: engagement, multidisciplinary and durability. It’s the holistic approach building on the relationship that is going to lead us to making sure that more and more vulnerable populations will get their treatment and ultimately be virally suppressed.
For more information, visit www.vidc.ca.