Maximally Assisted Therapy (MAT) Program

Introduction

It’s a community of caring

MAT is far too small for the personalities it welcomes every day. Since 1999, the Maximally Assisted Therapy Program, known all over Vancouver simply as MAT, has cared for people living with HIV who face significant barriers to daily adherence to antiretroviral therapy. Since 2001, MAT has cared for its members in a crowded, busy, friendly and supportive section of the Downtown Community Health Centre.

MAT is not just a clinical response to the need to improve ART adherence: it’s “a community of caring,” according to Suzy Coulter, MAT’s previous clinical coordinator and now a casual nurse at the program, where any barrier—biomedical or psychosocial—to adherence is addressed by members of a committed and compassionate interdisciplinary team.

Some members have been coming to MAT for years. They come because there’s breakfast, because the nurses on staff know their veins and it makes their blood work easier, and because for many it has become a vital part of their routine. Mostly, members continue to come to MAT “because it’s a safe place, [where] they feel like they have a home away from home,” according to Fleur Sussman, a clinical pharmacist at MAT since 2000. Over the years, MAT’s waiting room has developed into an informal space where members can socialize and share their treatment successes and challenges.

It’s not always easy at MAT; tensions can flare, especially in fall and winter when it’s standing room only and people want to get out of the rain. “There are lots of things that can go sideways, in a…small waiting area,” says Sussman. A community agreement, which all members sign, outlines rights and responsibilities and offers some order in the chaos. Bans are rare at MAT, where the emphasis is on providing “vulnerable people a safe environment” while ensuring that all in need can access the program’s services.

The program is open seven days a week, with access to registered nurses, community liaison workers, a social worker and, uniquely for a program of this type, an onsite clinical pharmacist. As Christine Gillespie, the outgoing clinical coordinator, notes, “it’s a crucial point to the program” to have a pharmacist on staff and available to members who want to discuss drug interactions, side effects and optimal adherence. The pharmacists also keep the antiretrovirals moving with the member wherever they go—to hospital, drug treatment centre or jail—without interruption.

Although MAT has always sent out a daily outreach team in the afternoons, funding from the Seek and Treat for Optimal Prevention of HIV/AIDS (STOP) Project has allowed the program to take its services to the wider inner city of Vancouver. A full-time outreach team is tasked with reaching those with the most significant barriers to care and, through respectful support, helping them to reduce those barriers and re-engaging them in healthcare. Gillespie credits the work of this team with allowing MAT to more fully accomplish its mandate to reach those who experience significant barriers to care and treatment adherence.

This has meant that MAT’s demographic has shifted, with a significant increase in the number of members who are commercial sex workers, members who have co-infections and dual diagnoses and members who are extremely isolated and disconnected from the healthcare system, and as both Coulter and Gillespie noted, in members with severe and persistent mental health challenges.

As Sussman says, “It’s a family here.” MAT staff know that offering low-barrier, interdisciplinary, sometimes creative, always non-judgemental care and support can result in positive outcomes for a person’s health, and they apply this knowledge as they care for MAT’s members every day of the year.

What is the Program?

The Maximally Assisted Therapy (MAT) program provides access to antiretroviral therapy and adherence support in Vancouver’s Downtown Eastside. MAT is designed to be a low-barrier, one-stop health resource for people living with HIV; in addition to delivering HIV treatment, the program provides tailored treatment, clinical care and supports for its members that address their chronic and acute healthcare needs. For more information on similar programs, please see the Program materials section.

Most of MAT’s members experience complex health needs, including severe mental health issues and addictions, and face multiple barriers to accessing and adhering to HIV treatment. Many have a history of low adherence and would face significant barriers to accessing health services without the MAT program.

MAT minimizes these barriers through a multidisciplinary approach to health. The team includes a social worker, community liaison workers, nurses, an on-site clinical pharmacist (a full-time position shared by two people), a program assistant and a clinical coordinator. The program is open seven days a week and is housed at the Downtown Community Health Centre (DCHC), where clinical services are offered to MAT clients in the morning. Since its inception, MAT has provided outreach to its members in the afternoon. In 2011, MAT added a second full-time outreach team, which is funded by the Seek and Treat for Optimal Prevention of HIV/AIDS (STOP) Project.

MAT’s core funding comes from Vancouver Coastal Health. As of July 2012, the program has 130 active participants, 89 of whom receive antiretroviral drugs (ARVs) directly through MAT (daily, weekly, biweekly or monthly), 29 of whom use the program’s support services but receive treatment elsewhere and 12 of whom are in the engagement phase of the program but are not on ARVs.

Why Was the Program Developed?

The MAT program was established as a pilot project in 1999 in response to research findings indicating that people living with HIV in the Downtown Eastside faced significant barriers to accessing treatment in traditional settings, such as community clinics and hospitals. These findings came out of the Vancouver Injection Drug Users Study (VIDUS), which has been collecting data on Vancouver’s injection drug users since 1996. VIDUS also showed that, for the few who received treatment in the Downtown Eastside, adherence was a challenge. The MAT program was developed specifically to address the treatment access and adherence needs of people living with HIV in Vancouver who experienced the most barriers to care.

How Does the Program Work?

Location

MAT is located in the Downtown Eastside, a community with a significant number of people living with HIV and co-infections and who experience multiple and complex barriers to HIV care and treatment access. It was originally a pilot partnership between Vancouver Coastal Health and the BC Centre for Excellence in HIV/AIDS and housed in a storefront on East Hastings Street. In 2001, the program became permanent and moved into the DCHC. The transition to a community health centre setting provided MAT’s members with access to comprehensive primary and specialist healthcare, to addictions and mental health counselling and to a responsive, not-for profit pharmacy, services MAT could not provide from its storefront location. Since this transition, MAT has been funded through Vancouver Coastal Health.

Accessing the MAT program

Eligibility

In accordance with the MAT mandate, potential members must meet the following criteria to be invited to participate in the program:

1. They must be HIV positive and need assistance with managing their health.
2. They must live in the Vancouver inner city or be homeless and frequent the Vancouver inner city or receive medical care from a physician at DCHC.

Referrals to the MAT program

In almost every case, a person is introduced to the MAT program through a referral from a healthcare provider. Self-referrals are rare. MAT receives referrals in person, via phone or via fax. Referrals typically come from physicians, mental health teams, the STOP Outreach Team, an interdisciplinary clinical team responsible for improving engagement and linkage for people with the most complex barriers to care, housing support workers, hospitals and AIDS service organizations. All phone or in person referrals must be followed up with a completed referral form.

The referral form includes demographic information; how the referring agency sees this person meeting MAT’s mandate; clinical information, including viral load, CD4 count and treatment history; and any adherence barriers the potential member may be experiencing.

Once a referral is made, the clinical coordinator reviews the application for eligibility. MAT does not have a definite capacity limit, despite the fact that turnover in the program is low. Given that MAT’s mandate is narrow and only the most vulnerable are referred, the pool of people referred and eligible is limited.

When a person meets MAT’s mandate, the potential member meets with clinic staff to review the program’s services and expectations, the individual’s ART readiness and motivation (if they are not already on ART), and their needs and goals. Intakes are initiated between Monday and Friday, and a chart is opened as soon as the person agrees to enroll in the program. Nurses, community liaison workers, the social worker and the pharmacist will help complete this file. During this process, if the new member is on ART or receiving other medications for chronic or acute illness (except methadone), arrangements are made to transfer the management of all medications to MAT. Methadone is dispensed through the DCHC pharmacy.

Community agreement

To participate in the MAT program, each MAT member must sign a community agreement that outlines the program’s policies. It includes provisions on respect for others and prohibitions on verbal and physical abuse, harassment and intimidation of other members; damage to property; theft; and carrying or wielding weapons. Although people are welcome at MAT if they are actively using substances, they are not allowed to use or sell drugs on site.

When a member violates the community agreement, a care plan is developed that will facilitate their continued interaction with the program while ensuring the safety of MAT staff and members. Typical care plans include restrictions on attendance hours (e.g., a member cannot visit between 8:30 am and 10 am when the program is busiest) or limitations on the amount of time they spend in the space (e.g., a member is limited to one hour a day in the space starting from the time they walk through the door, with no ins and outs).

Addressing immediate needs

Once a person joins MAT, the first priority is to address any immediate health concerns. For people who are not currently on treatment, treatment is not started until an informal readiness assessment is done and any psychosocial or medical needs that might reduce treatment success are addressed. In most cases, this means addressing food security or inadequate housing issues, although it can include referrals for mental health and substance use assessments, treatments and therapies and for primary medical care.

The social worker plays a key role at this stage of the engagement process. About 50 percent of new members have little interest in talking about HIV or understanding treatment. It is usually their physicians who are keen to have them be part of the program. Most of the time, HIV is not the primary concern of new members. Rather, concerns about housing, food security or mental health and addictions preoccupy them. In the first few weeks, the social worker will work to determine what housing and other psychosocial services the new member has accessed in the community, both through discussions with the member and through Vancouver Coastal Health’s electronic heath records system. The social worker builds a picture of the member’s current needs and establishes a rapport with them.

Even if a member is eligible for but not on treatment, they might not be ready to adhere to medications. When readiness has been established (in consultation with the member, the member’s doctor and MAT staff), MAT staff will meet with the member, assess what is currently going on in the person’s life, and try to determine what challenges the member will face in adhering to treatment and how to manage them. Together they determine the start date that will provide the best chance for optimal adherence. Before starting treatment, members always meet with the clinical pharmacist to discuss treatment side effects, interactions and best dosing practices.

Treatment access: onsite

MAT offers ART in three different ways:

• through daily directly observed therapy at the MAT site
• through blister package for weekly, biweekly or monthly pickup at the MAT site
• through outreach to clients who do not or are unable to make it to the clinic (see Treatment access: outreach below)

The program determines the delivery method on the basis of the member’s needs and ability to store and take medications independently.

Onsite medication counselling and dispensing

One of MAT’s unique features is the inclusion of clinical pharmacists on the interdisciplinary team. As with all of MAT’s other services, no appointment is required to consult one of the pharmacists, and members who have any medication-related questions are free to drop by the pharmacists’ office when they visit the program.

The pharmacists provide treatment counselling before members start treatment and adherence support for those on treatment. They also provide expert information on drug interactions and side effects to members, physicians, the MAT team and other service providers involved in the member’s care. When members transition in and out of different facilities—hospitals and detox/recovery programs–or when they move to or visit regions outside Vancouver, the pharmacists help with medication procurement. This is crucial because ART medications do not show up on PharmaNet, British Columbia’s provincial registry of prescription medications, and unless a person discloses that they are on ART, staff at the hospital or in the recovery program will not know that that person is taking ARVs.

MAT’s clinical pharmacists do not prepare or dispense medications for MAT members. This is done through a partnership with the DCHC on-site pharmacy. In addition to their HIV medications, members get medications for their chronic and acute conditions packaged through this pharmacy, and all the medications are dispensed by the nurses in MAT. Currently, medications are blister packed by the on-site pharmacy.

Onsite directly observed therapy

As of October 2012, 52 of MAT’s 130 members receive their therapy daily onsite. MAT does not schedule appointments, so members are free to drop in anytime between 8 am and 2 pm, after which two staff leave to do outreach. If a member arrives after 2 pm, however, a staff person is still typically on site to help them. The majority of members come in between 8:30 and 10 am.

The MAT program waiting area has become a social space for members, an informal community of support. The program fosters this by creating a friendly non-judgemental environment that encourages members to come, have cereal, coffee and juice and socialize with other members.

On-site pickup of blister packages for weekly, biweekly or monthly dispensing

MAT serves 37 members on a more infrequent basis. These people are more stable or live outside of MAT’s catchment area. They check in on a weekly, biweekly or monthly basis to pick up their medications. These members are encouraged to drop by more often than their regular pickup schedule as required.

When a person arrives on site, a nurse checks in with them to see how they are doing; to determine if any care is outstanding, such as lab work; and to remind them of any upcoming medical appointment. These members continue to be at high risk for returning to less stable lives, and thus frequent contact is important, not only to monitor their ability to take their medications independently but also to provide stability and support.

It is not uncommon for members to move from weekly or biweekly pickup to daily observed therapy and back to more independent treatment delivery. Members are usually frank about the barriers they face to adherence and staff try to accommodate them as much as possible.

Proof that members are challenged by their regimen, however, is in their blood work. When viral loads spike and CD4 counts drop, MAT staff and the member will strategize ways to improve adherence and manage medication side effects; in consultation with the physician and pharmacist, they may also adjust their regimen as needed.

When members do not show up at the usual time to pick up their blister-packed medications, a phone message will be left for those who have access to a phone. With the permission of the member, MAT will also contact other agencies that the member frequents. If the member lives in the DCHC’s catchment area and cannot pick up their blister pack, an envelope containing one day’s worth of medication will be delivered to a pre-determined location for two consecutive days.

A note will be mailed to those living outside the catchment area after two missed days of medication. Sometimes, a blister pack will be delivered during outreach hours to members who cannot make it to the clinic. In the event that this occurs, the clinical coordinator will be informed and a MAT communication will be sent to the member’s physician. Members who continually fail to collect their blister packs are reassessed to determine a better delivery option.

Treatment access: outreach

The MAT program delivers treatment, care and support to members in the community through two distinct outreach teams. For the purposes of this case study, the daily afternoon MAT outreach team, which has been a part of MAT since 1999, will be referred to as the first outreach team. The new outreach team, established in 2011 through funding from the STOP Project, will be referred to as the second outreach team.

The first (MAT) outreach team

Since its inception in 1999, MAT has had an outreach component. Outreach is done on foot every afternoon between 2 pm and 4 pm by a registered nurse and a community liaison worker. The purpose of outreach is to find those who have not come to MAT for their daily ART. On an average day, the team connects with 10 to 20 members. In addition to bringing the medications to be dispensed, the team carries juice boxes and yoghurt, gloves, supplies to take vital signs, hand sanitizer and other outreach supplies. For security reasons, the names and addresses of those who are being served through outreach are given to staff remaining in the clinic and the team carries a cellphone.

The MAT outreach team’s focus is medication delivery; if the team is to reach all those who need outreach services each day, there is little time to provide more than a cursory offer of other services or to conduct an extensive search for members. The team is usually unable to find half of those who are on the outreach roster on a given day.

When a member is not at home, the team visits any alternate hangout sites the member mentioned during intake. This can include parks and friends’ rooms. Medications are only dispensed in public if the member has given prior permission. When a member cannot be found, medication will be dropped off at a predetermined location. For instance, medication might be left under the door of the member’s room or with a tenant support worker. Some MAT members have given staff a key to their apartments so they can enter and leave medications in their absence. Medications are never left with hotel managers or slipped under the doors of homes where children live. If children live in a member’s home, MAT will provide a lockbox for medications.

Medications will only be dropped off for three consecutive days. After that, the outreach team will continue to visit but will not leave medications. Staff will start investigating the whereabouts of the member by contacting their landlord and other service providers involved in their care and by checking with hospitals and jails. The physician will be notified that the member has not been observed taking their ARVs, at which time the member’s regimen may be reassessed to find an arrangement that better fits their needs and circumstances.

Given that the purpose of MAT is to offer services that accommodate the individual needs of its members, if its services do not work for a member, staff will work to find ones that do. This may include providing more psychosocial support at MAT, referring the member to the second outreach team or transferring the member’s medications to a different clinic, program or pharmacy.

The second (STOP) outreach team

Since 2011, a STOP-funded outreach team—the second outreach team—has exported MAT’s mandate beyond the traditional catchment area to serve the wider inner city of Vancouver. Like the first outreach team, this team is comprised of a registered nurse and a community liaison worker, but it operates with different hours: Monday through Friday usually from 9 am to 3 pm. The first and the second outreach teams have separate caseloads.

Unlike the first outreach team, the second team works with clients who may not yet be members of the MAT program, thereby extending the reach of the program. Most of this team’s clients are referred by healthcare providers, although some referrals come from tenant support workers and other outreach teams working in Vancouver. In rare cases, a self-referral is made. The number of people on the outreach team’s caseload is fluid; there are usually between 20 and 25 people on it at any given time. Most of the people on the caseload are women who have been lost to care. Some MAT members who became engaged in MAT through this outreach team have moved through MAT’s program and now receive their ART in weekly blister packs.

The staff of this outreach team create relationships by being persistent but non-intrusive. They offer more in-depth services than the first outreach team: they provide nursing care—directly observed HIV treatment and other primary healthcare—and social support. Depending on the member and on the day, visits might be brief and focus only on checking in and delivering medications or they might be longer when issues have arisen that the member wants to discuss. The team provides referrals for housing and food security programs and assistance getting to food banks, medical appointments and other community services.

The team uses extreme sensitivity in its interactions with new referrals and is careful never to push too hard to engage someone. They approach each encounter as if it is the most important one of their day, and they always leave things open ended with members. The team also strives to, above all else, protect the privacy of their clients. MAT’s mandate is restricted to offering services to people living with HIV and so any encounter with the team could reveal to a member’s neighbours and friends that they are HIV positive. To reduce this risk, the second outreach team identifies itself as generically as possible, usually as the DCHC’s outreach team rather than as a MAT team.

With the consent of members, the second outreach team will liaise with other care and support providers in the community who might be involved in their care, including doctors, to provide the best possible service. In addition to these strong partnerships, the team operates closely with the other MAT staff, raising issues and sharing information with the social worker, the clinic coordinator and the pharmacists and with the doctors at DCHC.

There is strong anecdotal evidence that this outreach team is successfully reaching the people with the most barriers to engagement in care in Vancouver’s inner city. Since the establishment of the second outreach team, MAT has observed a shift in the demographic that it serves. Many of the new people it is reaching have severe and complex mental illnesses and addictions and many are women with a history of work in the sex trade.

Engagement without treatment

MAT has 12 members who are not on medication but who have been engaged in MAT’s services. These people face more entrenched barriers to treatment adherence than other members. Several of them experience complex and severe mental illnesses, combined with substance use. With these individuals, the primary goal is for outreach staff to build a trusting relationship with them and address any of the immediate food, housing or health needs they might have. For some of these individuals, this link with MAT, however tenuous, is their only link to healthcare.

Support services without treatment

Less that 20 percent of MAT’s members use its social supports but receive their HIV medication elsewhere. For some of these people, treatment is offered through other medication management programs, such as the Vancouver Native Health Society’s Positive Outlook Program or the Dr. Peter Centre. Some MAT members have their medications dispensed daily through a community pharmacy. Others self-manage their medications. These members prefer to come to MAT for certain aspects of their care because the nurses know their veins (which can be damaged by years of frequent injections) and this makes blood draws easier or because they have a relationship with the social worker.

Requests for temporary carry of medications

Occasionally, MAT members make requests to get several days’, weeks’ or a month’s supply of their medications. These are called carries. These requests are assessed on an individual basis, and decisions are based on the following criteria: the member’s adherence to their ARV regimen in the last month, their mental health status, the extent of their current drug and/or alcohol use, and the member’s ability to safely and appropriately store medication. For those who cannot carry, attempts are made to make arrangements for medication delivery at their destination.

MAT has set up guidelines for members who may become involved in the provincial or federal justice systems, for those who may enter a detox or a treatment centre and for those moving within and out of the province.

The transfer of medications to different institutions is coordinated by one of MAT’s clinical pharmacists. Most pharmacies do not stock supplies of ARVs, so orders must be made from a hospital in Vancouver (St. Paul’s Hospital) and shipped to the member’s final destination. In these cases, one- to two-week carries are often given to ensure that treatment is not interrupted.

Graduating from MAT

Although MAT does not have an explicit mandate to graduate its members to less intensive forms of treatment delivery, a few members have moved on to less intensive care at MAT (weekly or monthly dispensing) or at other programs in Vancouver, and some have moved on to self-management.

Developing a more robust self-management program for members would be an area of growth for MAT. This would involve developing goal-setting plans with MAT members that would facilitate their transfer to less intensive adherence support programs when they are ready. This is an important component in creating greater flow-through and maintaining sustainable capacity for the program.

Some of MAT’s members continue to need MAT’s intensive approach for years after they become engaged in care. Staff continue to work to reduce barriers to treatment and to offer the services those members need to stay engaged in care.

Required Resources

Clinical Coordinator: 1.0 full-time equivalent (FTE). Coordinates staffing, schedules, referrals and day-to-day operations. Available Monday to Friday.

Community Liaison Workers: 2.8 FTE (1.0 FTE is STOP funded). Provide day-to-day support for members, manage waiting room dynamics, serve breakfast, help members apply to food support programs and for bus passes, and support the work of the social worker. Alternate with social worker to provide daily outreach. Available seven days a week.

Pharmacist: 1.0 FTE. Two pharmacists share this role. Prepares medications and offers counselling on adherence, side effects, drug interactions and how ARVs might interact with other chronic or acute care medications members are taking. Available Monday to Friday.

Program Assistant: 0.6 FTE (STOP funded). Provides administrative support at MAT. Available Tuesday, Wednesday and Thursday.

Registered Nurses: 4.5 FTE (0.8 FTE is STOP funded). Dispense medications and provide primary care. Provide daily outreach. Available seven days a week.

Social Worker: 1.0 FTE. Does long-term intensive HIV case management for all 130 members, including appointment tracking; applies for disability benefits, housing and housing supports for members. Provides accompaniment services, home visits and advocacy. Alternates with community liaison workers to provide daily outreach. Available Monday to Friday.

At any given time, MAT has at least four people on duty in the clinic. Security guards with sensitivity training are on hand seven days a week to ensure that members honour the community agreement and to ensure the safety of members and staff alike.

Because MAT is housed in the DCHC, its members have access to the services and programs that DCHC offers. DCHC has a nutritionist, respiratory therapist, doctors, nurses, licensed practical nurses, nurse practitioners and visiting specialists, including an infectious disease clinician and a podiatrist. It also offers tuberculosis services from the BC Centre for Disease Control, complementary therapies, addiction and mental health counselling, home support, financial management support and pharmacy services. DCHC is not served by a psychiatrist; members who are referred for psychiatric and other services not offered at DCHC are accompanied to their appointments by the MAT social worker or a community liaison worker.

Challenges

1. Space. MAT is challenged by the space it occupies. The space is small and the waiting area fills fast as people come in to get their medications and linger to socialize. Ideally, MAT would have a dedicated exam room, a dedicated meeting space for formal support groups for members, more office and storage space, and a full kitchen, which would enable staff to offer more nutritious meal options.
2. Severe mental illness. The increase in the number of severely mentally ill members has been a challenge for MAT. They require more intensive interventions and are less likely to adhere to their medications, if they consent to take them at all.
3. Service coordination and communication between providers. The plethora of services available in the Downtown Eastside can make coordinating care and services difficult. Often, the number of programs implicated in a person’s care can result in a lack of follow-up and thus gaps in service. To address this challenge, a point person may be designated to care for an individual member’s housing needs. Comprehensive files are kept at MAT on each member to ensure that all staff are working together rather than duplicating services.
4. Cheque day. Perhaps the most difficult week of the month is the week that social assistance cheques are issued. MAT is deserted on what the program staff refer to as cheque day. In the days before cheques are issued, MAT staff encourage members to come to the MAT site before they pick up their social assistance cheques or offer them the option to carry two or three days’ worth of treatment with them. The outreach caseload usually doubles during this week.
5. Systemic issues. Systemic issues that affect members’ health and well-being continually challenge the MAT program. Issues include insufficient housing for people living in the Downtown Eastside, limited long-term or assisted living spaces for seniors with past or active addictions, an insufficient number of mental health programs that will treat people with active addictions, and the lack of availability of a detox or treatment bed when a person requests it.
6. Population-specific services. MAT does not offer a women’s only program. Seventy percent of MAT’s clientele are men, and some women feel intimidated coming into a space that is dominated by men.

Evaluation

MAT has always kept detailed health records, which it uses to monitor and evaluate its performance. Since receiving funding from STOP, MAT has been asked to give regular reports to STOP on new referrals, ARV starts,  CD4 counts and viral loads. MAT staff track and compile these data through an electronic health record system and intensive monitoring of client blood work.

MAT has never undergone a formal evaluation of the social supports it offers; however, staff have observed that social supports contribute to improved health outcomes for members.

Lessons Learned

1. “Super low barrier. That’s why we work.” MAT has removed any barrier that may impede a person’s ability to get treatment. The referral process can be completed in a single visit, and from the time members join the program, they are free to drop in every day of the week to receive interdisciplinary care. Being housed in a community health centre allows MAT to address the immediate healthcare needs of a population that may not be able to wait to access primary healthcare or pharmacy services. Members are also welcome to come high or drunk. If they exhibit troubling behaviour in the MAT space, a care plan is developed that allows them to continue to receive care. Staff may ask them to leave for the day, after they have received their medication. If they cannot make it to MAT, the program offers outreach services.
2.  “Every encounter is an important one.” Relationship building is the fundamental principle of MAT. When members first join MAT, the intensive engagement and psychosocial support from the social worker always provides them with a higher level of comfort with the program and in a more active interest in MAT and in treatment. Providing such intensive support at every possible turn allows MAT staff, both at the site and on outreach, to help people break down the barriers that prevent them from seeking treatment and care and to engage them in more independent self-care.
3. “There’s no cookie cutter approach.” Every member’s care plan is individualized so that each member receives the care and support they need and want.
4. “It’s a family here.” Friendly, warm and non-judgmental reception is key to getting people to come back.
5. “We enter these little communities of people.” Respectful and sensitive outreach is a critical component of MAT’s success. It allows MAT to reach people who cannot come to the MAT space daily, who live outside MAT’s traditional catchment area or who, for whatever reason, do not want to seek an HIV-specific service to receive care.

Contact Information

Kris Stephenson, MAT Program Clinical Coordinator

Downtown Community Health Centre

569 Powell Street
Vancouver BC  V6A 1G8

604-255-3151 ext 304
Kristine.Stephenson@vch.ca

What is the STOP HIV AIDS Project?

Seek and Treat for Optimal Prevention of HIV/AIDS (STOP) was a $48 million, four-year (2010-2013) pilot project funded by the government of British Columbia. This project aimed to increase the quality of life of people living with HIV and reduce the number of new HIV infections by taking a proactive public health approach to finding people living with HIV, linking them to HIV care and treatment programs, and supporting them to stay in care. STOP aimed to improve the experience of people living with HIV or AIDS in every health and social service interaction and significantly improve linkage and engagement across the full continuum of services in HIV prevention, testing and diagnosis, treatment, and care and support.

STOP was rolled out in Vancouver and Prince George. It was made up of numerous interconnected and discrete clinic-based, hospital-based, community-based and policy-focused programs implemented through the collaboration of a significant number of stakeholders. In Vancouver, Vancouver Coastal Health and Providence Health Care partnered to form the Vancouver Project. Through this partnership, these two organizations shared governance, funding and reporting for many of the initiatives that took place in Vancouver between 2011 and 2013.

In 2011, the MAT program received STOP funds to expand its services. The program hired a program assistant to support staff to track clinical outcomes. It also hired a full-time outreach team, consisting of one registered nurse and one community liaison worker. This has allowed MAT to bring its comprehensive approach to HIV care, treatment and support to people outside its traditional member base who may need a program like MAT to access HIV treatment.