What is the program?
The Vancouver Infectious Diseases Centre (VIDC) developed community pop-up clinics (CPCs) to engage people who use drugs in chronic infectious disease treatment (e.g., hepatitis C) using a low-barrier model. Through partnerships with housing societies and community organizations in the inner city of Vancouver, the VIDC conducts CPCs one to three times weekly to complete point-of-care hepatitis C and HIV testing and engage people in care.
The VIDC provides care for chronic infectious diseases, with a focus on hepatitis C and HIV, by leveraging a multidisciplinary team to provide holistic services including mental health support, management for substance use and assistance with social supports (e.g., housing or financial assistance paperwork). Their satellite clinic located in the heart of the inner city, the Vancouver Urban Health Centre (VUHC), also uses a low-threshold multidisciplinary model to provide wrap-around care to patients identified through the CPCs.
Why was the program developed?
Vancouver’s inner city, particularly the Downtown Eastside (DTES), has a high prevalence of hepatitis C and HIV infection, with many individuals disconnected from the healthcare system. This area has a considerable population of people who use drugs, who may be at increased risk for hepatitis C and HIV transmission, leading to a disproportionate burden of these diseases in this population. Moreover, this population experiences significant barriers in accessing healthcare and is frequently disconnected from services because they face more pressing issues (e.g., housing and financial insecurity, mental health issues). Given that over 25% of people in this area are estimated to be affected by hepatitis C and up to 2% live with an HIV infection, low-barrier strategies are needed to reach and engage individuals in this population in the cascade of care.
While the VIDC has a long-standing practice of engaging marginalized populations in inner-city Vancouver, the CPCs were developed to further reduce barriers to healthcare. Additionally, Canada’s commitment to the elimination of hepatitis C and HIV as a public health concern necessitates innovative strategies to maximize the initiation of hepatitis C and HIV treatment. This program plays a crucial role in scaling up treatment rates by identifying those in need of hepatitis C and HIV treatment and ensuring they remain engaged in care. In doing so, the CPCs help reduce the risk of hepatitis C and HIV transmission.
How does the program work?
CPCs are weekly events that typically take place in single room occupancy (SRO) buildings and shelters in the DTES of Vancouver, with some events being held at community centres, supervised consumption sites or the VUHC. The CPCs are staffed by the VIDC Outreach Team, which consists of at least one nurse, a peer support worker, an outreach worker and one other clinic staff member. A physician is available for telehealth consultations as necessary. The CPCs are organized by an outreach director, who coordinates with building managers to schedule testing events. VIDC staff provide the manager of an SRO building or shelter with details of the CPC and a promotional poster that can be used to advertise the CPC among residents before the event.
The VIDC has established agreements with three key housing societies located across inner-city Vancouver: Atira Women’s Resource Society, Lookout Housing and Health Society and Lu’ma Native Housing Society. These agreements allow CPCs to take place at the SRO buildings and shelters operated by each respective society to enable the systematic identification of individuals in need of hepatitis C and HIV testing and treatment.
Across all settings, CPCs are typically set up in a common space, such as in the building’s lobby, lounge area, kitchen, or front desk area. If a CPC event is taking place at an SRO building or shelter, the team sets up a testing station at a table, then the outreach worker goes around the building and knocks on doors to inform residents of the event. In SRO buildings and shelters with 30 to 90 residents, the team serves up to 30 residents per event over approximately three hours. The CPCs previously utilized a mobile van fully equipped with supplies required for medical care, including blood draws and physical examinations. However, strengthened community partnerships in the DTES have shifted the focus of CPCs toward serving inner-city residents rather than people living in other areas of Vancouver.
Hepatitis C testing and follow-up care
During the CPC, nurses and staff conduct onsite point-of-care testing and/or a review of the patients’ provincial medical records to determine if a hepatitis C infection is present (see paragraph below for information on HIV care). If a patient has hepatitis C antibodies, they are offered onsite blood work for confirmatory RNA testing. If they have a known hepatitis C infection, they have an immediate consultation with a nurse. If patients later receive a positive RNA result, an outreach worker will immediately attempt to schedule a follow-up appointment, either by phoning the patient or visiting their place of residence. Outreach workers can also assist patients by attending an appointment at the VIDC or VUHC with them or by facilitating a telehealth appointment for them with a physician or nurse practitioner, where the patient will start their hepatitis C treatment and establish a multidisciplinary care plan tailored to their specific needs.
If a patient misses their follow-up appointment, the VIDC Outreach Team re-engages them by revisiting their residence to deliver hepatitis C treatment or by implementing other follow-up strategies. These may include leaving reminders at their regular pharmacy or engaging neighbours, friends, partners or SRO building staff to identify locations where they may be able to connect with the patient. The VIDC also employs a case nurse manager to offer broader healthcare services alongside hepatitis C diagnosis (e.g., COVID-19 and influenza vaccines, substance use care) in partnership with the Lookout Housing and Health Society, which helps to increase the uptake and credibility of the CPCs.
To streamline treatment initiation, the VIDC has partnered with the SRx Pharmacy, which is located beneath the VUHC and is experienced in managing care for people who use drugs, opioid agonist treatment (OAT) recipients and other marginalized populations. Several hepatitis C treatment dispensing options are available to meet the individual needs of each patient. Members of the VIDC Outreach Team (usually an outreach worker) or a member of the SRx Pharmacy outreach team can deliver the patient’s medication to their place of residence daily or weekly; if the patient has no fixed address, they can pick up their medications from a conveniently located pharmacy. Many patients are on a daily dispensing schedule for OAT or other medications, so the SRx Pharmacy often coordinates the patient’s hepatitis C treatment with this schedule. The pharmacy also provides reminders and support for patients to pick up their medications at the pharmacy. As such, this partnership promotes treatment adherence by ensuring patients have low-barrier access to their medications. Patients can reach out to the clinic with any questions or issues, and a member of the VIDC Outreach Team also conducts regular visits to check in with patients who may need additional support.
HIV testing and followup care
HIV testing follows a similar care format, with much of the testing conducted by nurses using rapid test kits during CPCs. Although newly diagnosed cases are rare, many patients previously diagnosed with HIV lack a regular physician or have been disconnected from care, often having multiple providers, and therefore they do not have a suppressed viral load. The VIDC Outreach team helps to re-engage patients by coordinating care, ensuring blood work is completed and sending assessments and referrals to other providers to maintain comprehensive care. Additionally, patients with outdated antiretroviral therapy regimens may be transitioned to newer medications that are safer, more effective and easier to manage, reducing side effects and improving overall patient health outcomes.
Required resources
- An outreach team consisting of:
- a nurse
- a peer support worker
- an outreach worker (a minimum of one nurse and one outreach or support worker is required at each event)
- HIV and hepatitis C point-of-care testing kits
- Phlebotomy supplies for onsite blood draws for confirmatory RNA testing
- Medical supplies for physical examinations and wound care
- Partnerships with local housing societies and/or community organizations to host the CPCs
- Partnership with a pharmacy experienced in managing care for people who use drugs, OAT recipients or other marginalized populations (not required but very helpful)
- A clinic space and available physician for in-person and virtual follow-up appointments
- A mobile clinic van stocked with medical and phlebotomy supplies (dependent on geography and need)
Evaluation
Between January 2021 and August 2023, 112 CPCs were held. Over the course of these events, 1,968 individuals were engaged in point-of-care hepatitis C testing or had their existing hepatitis C infection status determined through medical records.
Among the 1,968 patients engaged through CPCs:
- 620 (31.5%) had hepatitis C antibodies
- 474 (76.5%) of those who were antibody positive received a positive RNA result
- 387 (81.6%) of those with a positive RNA result were engaged in care
Of those engaged in care:
- 326 (84.2%) initiated treatment
- 60 (15.5%) were in the pre-treatment phase
- 1 (0.3%) died from an overdose
Among the patients who initiated treatment:
- 304 (93.2%) completed treatment
- 18 (5.5%) were currently on treatment
- 3 (0.9%) withdrew from treatment
- 1 (0.3%) died from an overdose during treatment
Of those who completed treatment:
- 286 (94.1%) were cured
- 16 (5.3%) were awaiting sustained virologic response (SVR) testing
- 1 (0.3%) who achieved SVR was subsequently reinfected
- 2 (0.6%) experienced a virologic relapse
Among the 1,388 patients who completed a demographic questionnaire, the median age was 45 (range 20–93) years, with 34.9% of patients identifying as female, 32.3% identifying as Indigenous and 50% identifying as Caucasian. Many patients reported experiencing housing insecurity (62.6%), incarceration (58.9%) and recent drug overdoses (47.1%). Most patients (79.7%) reported using opiates, with 63.9% reporting using amphetamines, 48.5% using cocaine and 22.8% using benzodiazepines, and many patients reported engaging in polysubstance use.
Challenges
- A lack of funding and limited personnel restrict the ability to provide testing to all residents in each building at a single event.
- Barriers related to provincial pharmacare requirements and turnaround time on blood work results make it difficult to start patients on treatment in a timely manner. However, time to treat has been reduced by providing on-site phlebotomy, special authority requests that reduce treatment coverage barriers and telehealth visits.
- Some patients frequently migrate between different locations in the city, which necessitates relationship building with patients and holding CPCs regularly across different locations.
Lessons learned
- Organizations need to meet individuals where they are at!
- Peer support and outreach workers are crucial to the success of these programs.
- Some individuals just aren’t ready to start treatment at the first encounter, but continued engagement, follow-up and assurances to individuals that they can engage in treatment at any time encourage individuals to engage in treatment when they are ready and able to do so.
Contact information
Brian Conway, MD, FRCPC
President and Medical Director
Vancouver Infectious Disease Centre
201-1200 Burrard Street
Vancouver BC V6Z 2C7
Canada
Phone: 604-642-6429
brian.conway@vidc.ca