Views From the Front Lines: STOP HIV/AIDS
We asked three people to share their views on British Columbia's innovative STOP HIV/AIDS Project:
The STOP HIV/AIDS pilot project has been running since 2009/2010. Looking back at the past two years, what would you say are some of the key lessons learned?
Although we were doing many things very well in terms of HIV testing, linkage to care, treatment and support, we've learned that there were a number of significant gaps. We've used STOP as an opportunity to purposefully reflect, with a broad range of partners and stakeholders, on how we were doing given the current state of the epidemic in BC and to identify innovative ways to address some of the gaps.
In the case of HIV testing, we were using testing approaches and policies that hadn't been significantly revised since the early days of the epidemic. We were essentially testing people based on assumptions about their level of risk. This approach is flawed because it assumes that individuals at risk know and understand their risk and that clinicians can accurately and consistently identify people at risk. Several studies, such as Vancouver's ManCount study, demonstrated that even among populations with the highest incidence and prevalence of HIV, there were significant gaps in their ability to identify their own risk and in the ability of clinicians to identify risk.
We also learned that approximately 60% of people diagnosed in Vancouver had CD4 counts below 500. This means that they were diagnosed later than the point at which they should have already started treatment, according to current treatment guidelines. Of those, approximately 40% of people were being diagnosed with CD4 counts of 350 or lower; and roughly 20%, with a CD4 count below 200. Clearly, a large proportion of people were being identified as HIV-positive too late for them as individuals to have the best health outcome. And, from a population perspective, we weren't doing all we could to prevent transmission.
The current method of targeting specific populations meant we were missing many people. As part of STOP, we've implemented an approach that doesn't replace targeted HIV testing (there will always be a need for testing that identifies a specific population, uses its language and has a high degree of cultural competency) but complements that approach with routine testing. We believe that through using both routine and targeted testing approaches at once, we might have a greater chance of diagnosing people closer to the time of their infection.
Since fall 2011, the four major acute care hospitals in Vancouver offer an HIV test to all patients upon admission. In just a few short months, we've already identified a positivity rate of approximately 0.5% and been able to provide a diagnosis to people who would have been very unlikely to have been diagnosed by any other means of HIV testing.
To your knowledge, what has the impact of STOP been on services for people living with and at risk for HIV? How has it changed or improved the patient experience?
We're trying to measure aspects of the patient experience in a couple of ways:
We're hearing that, in many cases, the patient experience is improving. People are being linked to care more quickly following diagnosis and have more comprehensive supports and services.
One of the initiatives we've received a lot of positive feedback about is our peer navigator services provided by Positive Living BC. The peer navigators, who are HIV-positive and have been provided with training and skills, are matched and made available to people who have been newly diagnosed. The peer navigator's role is to guide people through standardized information at their own pace and help them make the system work better for them. The clinicians also really like this because the peer navigators are able to have conversations that some clinicians aren't comfortable having or aren't able to have.
We've also seen positive outcomes on a continuum of housing support services, which we implemented as part of STOP. These services have helped retain people in care, stay on treatment, suppress viral loads ... but also, their overall health and well-being are going to improve with improved stable housing.
STOP has captured media attention nationally and internationally, and it has sparked controversy. While the strategy has been hailed as groundbreaking, some have also expressed concern that it may threaten people's privacy and autonomy. How do you respond to these concerns?
I think that some of the initial concern regarding privacy and autonomy resulted from fears that STOP would mean mandatory testing and treatment. As folks realized that all activities would be conducted according to current policies and guidelines, and building upon the recommendations of HIV-positive people and others, I think that many of those concerns have been addressed. We continue to encounter people who are relieved to learn that routine HIV testing means the routine offer of an HIV test with the requirement of informed consent.
This article was provided by Canadian AIDS Treatment Information Exchange. It is a part of the publication Prevention in Focus: Spotlight on Programming and Research. Visit CATIE's Web site to find out more about their activities, publications and services.
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