Peer HIV Testing

Introduction

“There was a feeling that together we’re working on something.”

For six months in 2011, the PHS Community Services Society (PHS), in partnership with the Vancouver Seek and Treat for Optimal Prevention of HIV/AIDS (STOP) Project, delivered low-barrier peer HIV testing events that brought the discussion of HIV to the street and celebrated the capacity of the community to provide solutions to its own challenges.

The events offered free food and entertainment to everyone, and a $5 gift card to any person who spent a few minutes speaking to a trained educator about HIV or took an HIV test, and to all people living with HIV who connected with a nurse for a comprehensive health checkup. According to PHS co-executive director Liz Evans, this initiative demonstrated that a “non-professional environment, a more community-based, grassroots relationship-based culture can access people and can deliver healthcare in a way that other systems can’t.”  

Over the course of 26 events, PHS, working side by side with nurses from the STOP Outreach Team, reached almost 5,000 people with rapid HIV tests and information, diagnosed 11 people with HIV and reconnected 324 people to care who already knew their HIV-positive status. According to Shelley Bolton, the peer testing project manager, the project was also a great way to update people’s information about HIV. “Being able to see nearly 5,000 people […] in a very short time, it’s a very efficient way to properly educate people and, in turn, they will educate their friends.”

By engaging peers to provide services, residents had an opportunity to contribute to solving their own healthcare challenges with their own solutions by using the capacity that exists in the community. Peers were trained by nurses to offer the test; nurses were available at every event to provide testing and care for people with symptoms of acute HIV infection, other sexually transmitted infections, AIDS-defining illnesses and for people who preferred to be tested by a nurse.

This hybrid model of HIV testing challenged assumptions about how and where healthcare should be delivered and by whom. According to Liz Evans, participants “felt so much more comfortable being tested by peers than they would have if it had been someone else.”

By training peers to become testers, the Vancouver STOP Project and PHS didn’t just reduce barriers to healthcare for residents of the Downtown Eastside, they also contributed significantly to community pride and engagement. “I like that part the most,” says Mark Townsend, co-executive director of PHS. “The pride that people felt that they were being part [of something]. Whether they were getting tested or doing the testing, there was a feeling that together we’re working on something. We’re working on getting people treatment if they need it. We’re working on stamping out AIDS.”

What is the Program?

The Peer Testing Project was a pilot that brought low-barrier, peer-administered HIV testing and support to the Downtown Eastside (DTES) through street fairs and testing events in community agencies and single-room occupancy hotels. The model challenged assumptions about how healthcare should be delivered and who should deliver it and, in so doing, significantly reduced barriers to access to HIV testing and linkage to care in the community.

The Peer Testing Project was implemented through a partnership between the PHS Community Services Society (PHS) and the Vancouver STOP Project. PHS Community Services Society is an organization that provides low-barrier health and social services and skills-building opportunities in the Downtown Eastside. It was originally called Portland Hotel Society, a reflection of its beginnings in the Portland Hotel. In 2003, PHS changed its name to acknowledge the expansion of its services at other sites. Many in the community still call PHS “Portland”, though that is no longer accurate. The Vancouver STOP Project is a collaboration between Vancouver Coastal Health and Providence Health Care.

The project represented a unique peer-healthcare provider relationship. Peers and nurses complemented the work of one another to offer the best HIV testing and linkage-to-care experience for people who experience multiple barriers to accessing healthcare. Nurses trained and supported peers to offer HIV testing and onsite nurses offered confirmatory testing for people receiving a preliminary positive result, as well as primary healthcare and psychosocial support to anyone requesting it. 

By hosting HIV testing events in public places and through a social marketing campaign, PHS hoped to reduce HIV stigma, update the community’s knowledge of HIV, begin a community dialogue about HIV and expand HIV testing and points of access to care and support for people living with HIV.

Over six months, PHS’s Peer Testing Project reached 4,773 people with rapid HIV tests and information, diagnosed 11 people with HIV and reconnected 324 people to care who already knew their HIV-positive status. While the number of people who attended PHS testing events and did not test or reconnect to care was not recorded, PHS estimates (based on the number of free meals handed out) that it reached twice as many people with up-to-date knowledge of HIV during these events.

With this model, PHS and the Vancouver STOP Project provided an opportunity to the community to contribute to solving its own challenges around access to information about HIV and testing and connection to care. They did this with community-driven solutions using capacity that exists in the community.

Why Was the Program Developed?

The Vancouver STOP Project was mandated to expand HIV testing in the city of Vancouver, including to people who experience significant barriers to healthcare. People in the Downtown Eastside experience multiple barriers to healthcare, including mental illness, addictions and poverty. Many have complex and concurrent health and psychosocial needs. Conventional medical spaces erect implicit and explicit barriers for marginalized people when they access services, and many feel judged and condemned in medicalized spaces or have a mistrust of medical authorities.

PHS Community Services Society (PHS) and the Vancouver STOP Project believed that training peers to provide HIV testing to each other in non-medicalized, safe and positive spaces would increase testing uptake in a high prevalence neighbourhood whose residents experience an ongoing risk of onward transmission of the virus.

In addition, they believed that organizing street festivals and small testing events to engage the community in HIV testing would also create opportunities for people living with HIV who were not connected to care to re-engage with the healthcare system. These events also allowed the wider community to update its knowledge about HIV risk, transmission and treatment.

The Vancouver STOP Project provided the funding and the clinicians, but needed the expertise of a strong community-based agency that could provide services to a community that traditional approaches to healthcare have not always effectively engaged. PHS, with its strong connections in the community, its peer-based service delivery model and a history of delivering low-threshold healthcare services effectively in the Downtown Eastside, had the ability to support the Vancouver STOP Project and effectively deliver this project.

How Does the Program Work?

Role of the PHS

Although this project was a partnership between the PHS and the Vancouver STOP Project, PHS took the lead in developing and implementing a low-threshold strategy that included removing the requirement that a clinician perform the test or provide counselling; on recruiting and supporting peers; in developing and rolling out the social marketing campaign; and in planning and implementing the community testing events.  Throughout this initiative, PHS and the Vancouver STOP Project aimed to remove barriers and fit the testing initiative to the community rather than the community to testing. 

Role of the Vancouver STOP Project

The Vancouver STOP Project provided the funding, education and training, and clinical support necessary to hold the events. Vancouver Coastal Health provided clinical oversight and direction on the design of the intervention, including developing tools and pathways for the peers to safely offer pre- and post-test counselling. Vancouver Coastal Health also designed the training and certification process with peers in collaboration with the BC Centre for Disease Control and by adapting materials from other organizations, including the World Health Organization.

In addition, the Vancouver STOP Project provided nursing staff during events through the STOP Outreach Team, an interdisciplinary clinical team responsible for improving engagement and linkage for people with the most complex barriers to care. During events, nurses provided initial screening of testing participants, provided HIV testing, primary care and linkage to care services, and provided clinical supervision to the peer testers.

Peer recruitment and training

Recruitment

Since its inception in the 1990s, PHS has engaged community members in service provision. PHS is deeply committed to low-threshold and peer-based work developed to reach people who have been poorly engaged by traditional services. It has a well-developed system of peers who frequently provide community services at its social enterprises and in its housing projects. Like all of PHS’s peer initiatives, recruitment for peer testers was handled through the PHS Life Skills Resource Centre. The centre has 6,000 members and through its employment program offers people opportunities to engage in various kinds of volunteer and paid work.

Peers already engaged in PHS services who staff felt would be good testers were approached and encouraged to attend an information session. These sessions were held to describe the initiative and the work peers would be doing. PHS staff, who are not necessarily peers, were also recruited to become testers.

PHS did not limit the number of people who attended the information session or the peer testing training. PHS operates on a model that encourages peers to engage in work they feel they can handle. In this model, PHS staff knew that peers who were not ready for the commitment would quickly self-select out. Generally, peers who were approached or self-identified as willing to participate were people who could follow the testing protocol, who could draw blood from a pinprick, who had a good bedside manner and who could communicate appropriately and effectively with clients.

Training

After attending an information session, people interested in becoming peer testers would participate in a training session led by Vancouver Coastal Health. The training was provided by nurse educators from the STOP Outreach Team, the VCH medical health officer and HIV practice leader, PHS’s project manager and bioLytical, the manufacturer of the INSTI^TM Test, the rapid test used by this project. Seventy peers and staff were trained to provide rapid HIV testing, which can be performed anywhere and offers results in 60 seconds.

The training covered the basics of HIV — prevention, transmission, window periods and treatment — as well as how to use the point-of-care (rapid) test kit safely and effectively. bioLytical provided training on the different components of the testing kit and how they were used. The training followed the BC Centre for Disease Control’s protocol for the use of POC testing and the World Health Organization’s HIV Rapid Test Training Package. Peers received standard Vancouver Coastal Health confidentiality and privacy training, agreed to adhere to these guidelines and signed a confidentiality agreement.  They also received training in ethics and public health follow-up. 

In pairs, participants in the training role-played through scenarios that occur when a rapid HIV test is offered. Training included how to offer pre-test counselling, answer often-asked questions, and offer negative results, indeterminate results or preliminary positive results. The peer testing project manager, a staff person at PHS, walked the participants through the way the events would be structured.

On the last day of training, each tester was required to pass a practical competency test administered by the STOP Outreach Team’s nurse educators. This test assessed each tester’s ability to perform and accurately read a point-of-care test based on the protocols set out by the BC Centre for Disease Control as well as their ability to deliver pre- and post-test counselling. During events, STOP Outreach Team nurses shadowed peers for at least five tests and administered a second exam during events to ensure competency and safety of practice.

The 20-hour training was offered to staff and more experienced peers over five days; less experienced peers, who might not have been able to handle a training environment for more than a few hours a day, were offered the training over a few weeks. Of the 70 participants in the training, 40 passed the practical competency exam. 

Those peers who did not complete the training or who did not pass the competency test were offered the opportunity to be paid educators at the testing events. These educators were present to assist with event logistics, offer information on HIV and point-of-care testing, and to answer any questions participants had.

Social marketing: the “Status Campaign”

In order to raise awareness about HIV testing and treatment as prevention and to encourage residents to participate in the events, PHS developed a social marketing campaign. The goal was to spread the word about the testing events and the importance of knowing your HIV status. Known as the Status Campaign and, using the taglines “A Positive Event” and “Know in 60 Seconds. Live a Lifetime,” the campaign distributed postcards and posters and maintained a social media presence to encourage people to get tested.

While the primary purpose of the campaign was to promote HIV testing, the media campaign was also produced to reduce stigma associated with HIV and to encourage people to believe that together they could stamp out HIV/AIDS.

The campaign was developed through a brainstorming session at PHS that included directors and staff and was based on PHS’s vision of obstacle-free and stigma-free HIV testing and diagnosis.

Testing events

Incentives

The Vancouver STOP Project and PHS provided incentives to people who took the time to improve their knowledge of and engagement with HIV during these events. This included people who spoke with a peer educator, people who took the test and people who were living with HIV and who received a comprehensive health checkup or reconnected to care through one of the nurses. The incentive was a $5 gift card to the Army and Navy store, which offers food and other essentials to residents of the Downtown Eastside.

This incentive was used to reach extremely marginalized people who were otherwise not engaged in conventional healthcare and was adapted from established practice in research studies where participants are rewarded for their time. As in research, the provision of an incentive facilitated the development of a rapport with marginalized individuals and met them where they were; for some, accessing healthcare would not have been a priority without an incentive.

Offering an incentive to access a healthcare education session to people living in poverty is perceived by some as controversial. PHS and the Vancouver STOP Project believed, however, that the benefits of providing the incentive (facilitating access to potentially life-saving information and healthcare) were clear. To mitigate the risks of offering an incentive to take a test that might change their lives, people could receive an incentive for speaking to an educator about HIV.  

The role of the nurses at testing events

Depending on the size of the event, between one and six nurses provided by the STOP Outreach Team were present at testing events. Nurses on this team are HIV specialist nurses who have  significant experience working in the Downtown Eastside. Some of the nurses have a public health designation, which means they are able to offer partner notification and contact tracing services. All are trained to offer HIV point-of-care tests and most have specialized sexual health training that means they can diagnose and treat common sexually transmitted infections.

Nurses were on hand at all events to provide testing to people who were ineligible or did not want to be tested by a peer. People ineligible for peer testing included people who had symptoms of an acute HIV infection, symptoms of an AIDS-defining illness, symptoms of a sexually transmitted infection, people who had significant mental health challenges, including suicidal thoughts, or who already knew they were living with HIV. Nurses also provided clinical supervision for peer testers testing people eligible for peer testing.

The STOP Outreach Team nurses were also responsible for public health follow-up of those who received a preliminary positive HIV test result at PHS events. On two occasions, someone who tested positive left the testing event before they connected with a nurse. In these cases, it was the responsibility of the STOP Outreach Team to follow up with these people in the community to determine if they were people who already knew their HIV status or if they were newly diagnosed. 

Testing events: Large, open-air testing fairs

Testing fairs: event set-up

PHS organized five large events, which were sometimes called testing fairs. These were hosted in Downtown Eastside parks and public spaces and attracted hundreds of people looking for information, testing and reconnection to healthcare. Typically, they took on a celebratory tone and were hosted by an emcee and featured day-long entertainment. Free food was available to anyone who attended. People who spent a few minutes talking to a trained educator about HIV, who tested for HIV or who knew their HIV-positive status and had a health checkup with a registered nurse, were given a $5 gift card. Other AIDS service and community-based organizations were invited to participate to raise awareness about their services. 

People who wanted to get tested or who were HIV-positive and wanted to reconnect to care were given a number at the information booth. When testers and nurses were ready for certain numbers, the emcee would make an announcement and direct those people to a reception area.

The reception area was separated from the rest of the event by a fence. There, 10 testing tents were set up in a circle with a resource table in the middle. Each tent was divided in two and numbered one through 20. Each tent was supplied with a fan, a testing bin,¹ a tester’s checklist, a testing flowchart that mapped out every contingency and a resource that explained each step of the testing process, including pre-test counselling, the point-of-care test and post-test counselling. The flowchart served as a reminder to the tester of the steps to follow during the test, but also provided the participant with information about what to expect from the testing process. These resources are available in the Program Materials section of this case study.

Nurses were available in a tent that was indistinguishable from testing tents for people diagnosed at the fairs or who already knew they were HIV-positive and wanted to connect with healthcare services. The layout of the testing events, including the decision to make the nurses’ tent indistinguishable from peer tents, maintained, as much as possible, the confidentiality of participants, if not their anonymity.

When a tester became available, a nurse would call the participant’s number and complete a brief screening to determine eligibility for peer testing. If the participant was eligible, the nurse would then introduce them to the tester. If the participant requested a different tester or a nurse, such requests were honoured. Very few people eligible to be tested by a peer asked to be tested by a nurse.

Testing events: Small events in community-based organizations

PHS also hosted 21 events in community-based organizations in the Downtown Eastside. These were held mostly in community spaces operated by PHS, including Insite, the supervised injection facility, Pigeon Park Savings, a credit union for people living below the poverty line, and PHS’ supportive housing projects. In addition, PHS used its existing good relationships with community agencies and private single-room occupancy hotels to build support in these organizations to allow PHS to offer HIV testing. At these events, between two and five testers would offer testing in partnership with at least one nurse, usually from the STOP Outreach Team.

Space constraints prevented entertainment from being offered at these events, but food was always available to anyone who stopped by for information. A $5 gift card was offered as an incentive to those who took a few minutes to speak to a trained educator about HIV, who got an HIV test or who were living with HIV and wanted to reconnect to healthcare.

Typically, these smaller events would attract far fewer people than the testing fairs, making it easier for people to ask for a test, receive it and get a meal in a short amount of time. Hours for these events varied in order to accommodate the schedules and habits of a variety of people in the neighbourhood, though most started in the late morning and ended by 7 pm. Two evening events were held until midnight to accommodate people preferring to test in the evening.

For a few smaller events at PHS sites, Vancouver Coastal Health (VCH) and PHS nurses trained to use the point-of-care tests by the STOP Outreach Team were authorized to support testing events. A protocol was developed to guide nursing practice at the events to ensure everyone tested received the same level of support. At the beginning of the event, a STOP Outreach Team nurse trained a VCH or PHS nurse on their role while supervising a peer-delivered testing event and on the protocols for follow-up and support.

When indeterminate results or preliminary positives were revealed during events where a STOP nurse was not present, the STOP Outreach Team’s public health nurses were contacted to handle follow-up. Follow-up with the individual was conducted at a later date. This process was outlined in the pre-test counselling session so participants were aware of the follow-up procedure in the event of a positive test and given the option to test elsewhere if they were not comfortable with that process. 

Testing and linkage to care

Although there has been a recent shift in pre-and post-test counselling in British Columbia toward a more streamlined pre-test discussion in lower prevalence settings, this project maintained a traditional pre- and post-test counselling approach. Given the high burden of HIV disease in the neighbourhood and potential marginalization of participants, testers offered in-depth pre-test counselling during events to participants seeking a test. Post-test counselling for people with reactive test results (preliminary positives) was completed by the registered nurse at the venue.

The typical interaction between the tester and the participant would take between 10 and 20 minutes. During this time, testers offered information on HIV risk, HIV transmission and the window period for an HIV test. Participants were informed that HIV is a reportable disease in British Columbia. This means that the medical health officer would be informed if the test were positive and any identifying information collected as part of the test would be relayed to a public health nurse so they could follow up and provide additional support to the participant and their contacts. Participants were offered the option to test nominally (with their real name) or non-nominally (initials only)  and were able to choose to provide contact information or not. If testing nominally, testers also asked participants where they would like to be contacted should any follow-up be required and if there were any special instructions regarding confidentiality. 

Testers also assessed readiness by asking people how they might react if the test were positive and whether they had a support system that would help them with the diagnosis. Testers were trained to request a nurse for further assessment and support before proceeding with the test if participants mentioned they did not have support or might feel suicidal if the test were positive. Participants were informed that if the test were positive, they would be connected to a nurse at the testing event for confirmatory testing and follow-up support.

Contact information for people whose test was reactive and who left the testing event without connecting with a nurse was given to the STOP Outreach Team’s public health nurses for follow-up. Follow-up was conducted so they could determine if the person had already tested positive elsewhere or if the person was receiving their preliminary diagnosis for the first time. This also allowed them to offer a linkage to care. 

Testers encouraged people who they did not believe could provide informed consent (such as those who appeared to be drunk or high) to test at a different time or with a registered nurse or physician.

Negative results

Those who screened HIV-negative were offered the opportunity to ask questions or be connected with a nurse for follow-up care, including referrals to housing, nutrition and financial support services, if they wanted it. They were also reminded about the window period for HIV infection and encouraged to test again in three months if they were at ongoing risk for infection. They were given a $5 gift card when they exited the fenced area.

People who tested negative but who identified a significant risk exposure to HIV were offered a blood test that can detect an acute or early HIV infection more accurately than a point-of-care test. 

Preliminary positive results

The peer testers were committed to providing the best possible care and support to all people with whom they interacted at the testing fairs. This support was particularly important to keep in mind for times when a rapid test revealed a preliminary positive result. When this happened, testers supported the person by answering any questions they had and then either calling a nurse discreetly to their station via the back door of the tent or walking the participant down to the nurses’ station for confirmatory blood work. Because many people went to the nurses’ stations or had a nurse visit their tent regardless of HIV status (for first aid, housing support, addiction services, etc.) it was not seen as breaching confidentiality to see a nurse. 

Participants who wanted additional support were connected to housing and meal programs and offered support with social assistance applications. Participants were also offered the opportunity to meet a peer navigator from Positive Living BC, an AIDS service organization invited to attend the testing events. Like people who tested negative, people receiving a preliminary positive result, who had received their confirmatory blood work and post-test counselling were given a $5 gift card when they exited the fenced area.

People living with HIV/AIDS

People who already knew their HIV-positive status and wished to be connected to care were also offered the opportunity to connect with nurses during these events. They were offered the same supports as people newly diagnosed with HIV. Usually, blood work was drawn to determine viral load and CD4 count. In total, 324 people were reconnected to care during these testing events. These people were also offered a $5 gift card.

Education and stigma reduction

It is estimated that 60 percent of participants at the testing fairs did not test or reconnect to care. However, because these people were reached with up-to-date messaging about HIV, PHS considers their participation in the event as part of the project’s success.

Throughout the day, peer educators circulated in the crowd and the emcees used their platform to speak about safer sex and substance use, about the HIV test and testing frequency, about modes of transmission, about the window period between the time a person is infected and the time antibodies against the virus show up in their blood, and about HIV treatment.

Testing in public opened up a space in the community to speak about HIV. PHS’s decision to hold festive events with the express goal of testing for HIV was an attempt to reduce HIV stigma in the community and underscored that HIV is no longer a death sentence.

Next steps

Since the summer of 2011, no large-scale peer testing events have taken place in Vancouver because funding for this initiative was time limited. The Vancouver STOP Project has, however, occasionally approached PHS to provide peer testers for public events, including Summer Solstice and Carnaval del Sol. Because incentives for testing are no longer offered, uptake at these events has been low. Regardless of the number of tests performed, the Vancouver STOP Project encourages the presence of the peer testers at these public events as part of its campaign to increase awareness and reduce stigma connected with HIV testing in Vancouver.

1. Testing bins included test kits, additional testing supplies (including pipettes and lancets), a table, medical gloves, hand and table sanitizer, a sharps bin for needles, biohazard bags for used gloves and test kits, pen and clipboard, water bottles and a tissue box.

Required Resources

Human resources

Event staff. Complete setup and takedown of event, greet and check in participants, manage lines, food and entertainment and supplies for nurses.

Nurses. Nurses trained to provide point-of-care testing and certified to provide sexual health screening and public health follow-up provide clinical support and public health follow-up.

Peer educators. Answer questions about HIV and HIV tests, provide accompaniments to appointments/referrals, provide peer support and support event logistics.

Peer testers. Members of the community able to handle blood professionally, communicate effectively and have a good bedside manner, and attend training and pass a competency test.

Project manager/event coordinator. Manages the logistics of the project and has some experience with event management and working with peers and nurses.

Material resources

All events

1. Confidential spaces that allow for private testing.
2. At least as much food as would be needed for twice the number of people who can be tested in a day. For example, if 400 people can be tested at a given event, food should be available for 800 people.
3. Enough rapid test kits and supplies for the number of people who can be tested, plus extra.
4. Incentives.

Testing fairs

1. Number system, which reduces wait times.
2. An area in which to greet people getting tested or connected to care.
3. An information booth for people to collect their testing number and receive other information.
4. Entertainment for up to 10 hours. This encourages a festive atmosphere and encourages people to participate in the event.

Challenges

1. Misperceptions of peer testing. The Vancouver STOP Project encountered concern among the city’s leaders in HIV testing that point-of-care tests would not be performed correctly by peers or at public events. There was concern that clinical protocols would not be followed and the appropriate reporting might not happen. However, the project was able to overcome this perceived barrier with the clinical and community partnership between VCH and PHS and a sound monitoring framework, which ensured that tests were performed correctly, protocols were followed and reporting took place.
2. Concerns about gaps in the continuum of care. Some healthcare providers were concerned about the continuity of care of people accessing care at testing events. Only positive results were communicated to doctors if the patient consented to sharing their test result. Some physicians felt that this did not allow them to adequately address the healthcare needs of their patients and did not give them a full picture of their patients’ health, such as when they had their last HIV-negative test. This was addressed by offering participants a business card with their HIV test results on it that they could share with their doctors. 
3. Counselling. PHS does not believe that counselling is automatically necessary during HIV testing. It considers counselling a barrier to testing for people who do not want to be counselled or who do not want to have to engage in public health follow up if they test positive. Despite this, counselling was offered by peers prior to each test because of the high prevalence of HIV in the community.

Evaluation

The Peer Testing Project was formally evaluated as a part of the Vancouver STOP Project’s monitoring and evaluation activities. For each test performed, testers completed a standard form. This form recorded information that included the date of the participant’s last HIV test, the test result for the current test (preliminary positive, negative or indeterminate), and whether the participant saw a nurse or if the STOP Outreach Team was contacted. PHS also tracked the number of people previously known to be positive who were reconnected to care. These forms were forwarded to Vancouver Coastal Health for data analysis.

In total, PHS performed 4,773 tests, diagnosed 11 people (eight men and three women) with HIV and reconnected 324 people to care. The majority of people reconnected to care were men (59 percent v. 39 percent women and 2 percent transgendered). Eighteen people from these testing events were referred to the STOP Outreach Team for intensive case management. The positivity rate for this initiative was 0.2 percent, double the widely accepted cost-effectiveness threshold for testing initiatives of 0.1 percent.¹

PHS also produced a final report of its own experience with this project, detailing the process it followed and the barriers it faced. The report also makes recommendations to the Vancouver STOP Project about how to improve peer testing and HIV services in the city. For a copy of this report, please contact PHS.

Impact: “There was a feeling of barn raising.”

The testing events represented an opportunity for the community to provide solutions to its own challenges. PHS continues to be approached by community members who want to receive the training to become peer testers, though the training is no longer offered. Many of the peer testers have gone on to find other employment in the community, which is a testament to the confidence the project built in some community members.

Public testing and discussion rejected the notion that HIV is different from other healthcare issues and contributed to the destigmatization of HIV in the community by providing a positive space in which members could face and discuss the challenges of HIV together. That summer, the dialogue that PHS opened up continued between events. PHS staff heard people talking about HIV testing in the neighbourhood and counselling their friends about risk reduction and why to get tested.

1. Walensky RP et al. Routine human immunodeficiency virus testing: An economic evaluation of current guidelines. American Journal of Medicine. 2005; 18:  292–300. Available from: https://www.amjmed.com/article/S0002-9343(04)00746-6/fulltext

Lessons Learned

1. Peer-nurse partnerships. Having onsite nursing support meant that people who tested positive or who already knew they were living with HIV were offered strong linkages to health and psychosocial programs. This linkage to immediate support improved the overall likelihood of continued engagement in healthcare. It also increased the safety of peer testing by screening out participants who would be best served by a registered nurse.
2. Training peers and staff to provide tests. Engaging both peers and staff as testers provided mentorship and support during events from trusted and familiar service providers.
3. Early and ongoing communication to the community. Improved engagement with other service providers in Vancouver prior to the launch of the project would have reduced misconceptions about providing incentives for testing in a neighbourhood where residents live in poverty.
4. Acceptability of peer testing. The peer testing events offered people the opportunity to seek low-barrier healthcare provided by people who understood them culturally. Knowing the peer performing the test was not a barrier to testing for participants, despite clinicians’ fears that peer testing would not offer people anonymity. Indeed, part of the success of the initiative was breaking down the belief that people always want anonymity when receiving an HIV test.
5. Mass education. By providing food and entertainment, testing became a community event. This was an efficient way to update residents’ knowledge of HIV, HIV transmission and the window period, treatment and how to reduce the risk of onward transmission. After events, PHS staff occasionally heard people who had attended the event sharing their knowledge with their peers on the street.
6. Incentives. Incentives were one of the ways used to reach an extremely marginalized group of people who would not otherwise have been engaged in healthcare. While incentives increased the risk of people testing repeatedly, repeat testers were infrequent and most were recognized by event staff before they tested. However, one participant who tested repeatedly and who was negative in June tested positive later in the summer, suggesting that repeat testing within the three-month window period may be appropriate in this context. Overall, the offer of an incentive helped develop rapport with the community. By offering a gift card to a local department store, the incentive also offered participants an opportunity to purchase necessities.

Program Materials

• Tester workflow
• Status event workflow
• Pre-/post-test counselling overview
• Tester checklist
• Status Campaign poster
• Positive Participant Education form
• Point of Care HIV Test Guidelines for Health Care Settings

Contact Information

For more information, please contact

Shelley Bolton, Project Manager
PHS Community Services Society
shelleyb@phs.ca
604-779-0452

For more information on Vancouver Coastal Health’s role, please contact

Meaghan Thumath, Clinical Practice Initiatives Lead HIV/AIDS
Vancouver Coastal Health
meaghan.thumath@vch.ca
604 314  8906

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 most of the initiatives that took place in Vancouver between 2011 and 2013.

With funding from the Vancouver STOP Project and clinical support and education from Vancouver Coastal Health, the PHS Community Services Society (PHS) expanded HIV testing by training peers to test residents of the Downtown Eastside. PHS hosted 26 testing events in the neighbourhood between June and October 2011.