Abstract
To the Editor:
E
People who use drugs (PWUD) account for 11.3% of new HIV infections in Canada and 17.8% of infections globally. 4,5 Transmission between PWUD tends to occur through the sharing of equipment (syringes and other paraphernalia), although additional transmission may occur due to concomitant risky sexual behaviors. 6 Many HIV-infected PWUD face additional challenges associated with suboptimal therapeutic outcomes with delayed ART initiation that may lead to disease progression and death. 7,8 Education-based interventions have shown notable promise in reducing stigma as well as risk behaviors that may lead to acquisition of HIV, as well as favoring retention in health care, a basic requirement for management of HIV infection among vulnerable populations. 9,10
Our center developed an HIV education and sexual health workshop through the Partnerships to Improve HIV Outcomes and Treatment program. Between 10/16 and 11/18, we conducted 24 educational HIV and sexual health workshops at nine community locations across the Downtown Eastside (DTES) of Vancouver, an area known for its widespread homelessness, mental illness, and substance use. 11 Educational workshops consisted of a 30-min PowerPoint presentation addressing topics such as HIV infection, transmission, treatment, and prevention. Participants were asked to complete a 15-point HIV knowledge-based questionnaire on the workshop topics pre- and postpresentation. Completion and collection of the first set of knowledge-based questionnaires was required before delivery of the educational presentation. The same questionnaire was administered postpresentation. We also offered HIV and hepatitis C (HCV) point-of-care testing after workshop completion. Engagement in care for individuals identified as infected with HIV and/or HCV was defined as attendance of at least one follow-up appointment at our center after the educational workshop.
A total of 451 individuals were recruited for knowledge-based testing, 179 of whom requested point-of-care antibody testing for HIV and HCV (OraQuick® Rapid Antibody Test, OraSure Technologies, Inc.). Key characteristics of participants included mean age 51 years, 70% male, 52% Caucasian, 46% marginally housed or homeless, 53% recent/current injection drug use, 64% reported using protective measures for sex (i.e., condoms) all or most of the time, 29% rated their current health as fair/poor, 7% of participants were men who have sex with men (MSM), and 57% indicated “acquiring knowledge about HIV” as the reason for workshop participation (Table 1). Knowledge scores were generated as a whole number out of 15. Questions varied from yes or no responses to multiple choice responses. Median participant scoring for the knowledge-based test results prepresentation was 8/15. Median scoring postpresentation was 9/15, representing a median increase in participant scoring by 1 point, with 141/451 (31%) recording an increase in score by 2 points or more. Incorrect participant responses were tabulated and related mainly to HIV transmission, testing, and pre-exposure prophylaxis (PrEP).
HIV Education Workshop Participant Demographics
Overall, 40% (n = 179) of participants requested point-of-care testing for HIV antibodies. In comparing this group with those who were not interested in such testing, we note mean age of 50 years for both groups, 74% versus 75% male, 64% versus 66% PWUD, and 9% versus 6% self-reported as MSM. The only factor associated with a request of testing was sometimes or never using protective measures during sex (45% vs. 28%). Although no new cases of HIV infection were identified, 14 people self-reported their HIV-positive status. Of those individuals, five engaged in care at our center of which four initiated ART at our center and one pursued treatment elsewhere. Nine individuals did not arrange a follow-up appointment at our center as six were already engaged in treatment elsewhere, two were not currently on treatment and chose not to engage in care at our center, and one individual self-reported HIV-positive status but subsequent antibody testing proved to be negative.
Point-of-care testing identified 31 cases of HCV infection, 23 of which were previously identified/self-reported. Fourteen individuals subsequently attended a follow-up appointment(s) at our center. Of the 14, 7 individuals remained engaged in long-term care at our center, 5 completed HCV treatment, all of whom achieved a cure. Two participants had already cleared their HCV infection but engaged in care at our center for long-term monitoring for hepatocellular carcinoma. Two participants were determined to not require additional follow-up postinitial appointment. Five individuals attended follow-up appointment(s); however, four subsequently pursued HCV treatment elsewhere and one was lost to follow-up. Seventeen individuals did not arrange a follow-up appointment. Of those, five were already cured and required no further follow-up, seven were successfully engaged in HCV treatment elsewhere, four individuals chose not to engage in care, and one individual who self-reported a prior diagnosis of HCV infection was subsequently determined to be uninfected by serological testing.
The format of a pre- and postintervention questionnaire met its stated goals of measuring baseline levels of knowledge and determining if a single structured intervention would have any impact on HIV and sexual health knowledge. On average, some new information was acquired and retained in the majority of individuals. In some (31%) more significant learning occurred (2 or greater points improvement). Knowledge about PrEP was particularly lacking. We will design educational initiatives focused on this area going forward, given the potential high impact of this intervention. Although no new HIV diagnoses were made, there were 14 individuals who presented to our workshops who were previously diagnosed with HIV infection and were not adequately engaged in care. Consideration will have to be taken, going forward, to maintain this newfound re-engagement in care. Ongoing iterations of the program will incorporate a peer support worker to increase the credibility of the educational content and to further enhance linkage to care when this is needed.
Addressing the HIV pandemic particularly among vulnerable inner-city populations (especially PWUD) will require novel approaches to identify those who are infected, engage them in care, and provide them with pertinent education about the disease. Our educational workshops, focused on HIV and sexual health, served as a unique tool to engage inner-city vulnerable populations on Vancouver's DTES. It was notable that knowledge about PrEP was particularly lacking. As its use has been associated with major reductions in HIV transmission, we will design educational initiatives focused on this area going forward, given the potential high impact of this intervention. 12
In addition to providing knowledge, our program served as a powerful tool of engagement, successfully linking 12/14 HIV-infected and 26/31 HCV-infected individuals to care. Powerful cost-effective interventions such as the one we describe should be included within public health programs designed to address chronic viral infections in this unique population and may also improve the quality of life of men and women for whom more traditional interventions have failed.
Footnotes
Acknowledgments
We thank ViiV Healthcare whose support and funding contributed to the piloting of this educational program. As well, we would like to recognize Vancouver Infectious Diseases Centre patients, staff, and supporters, who are committed to the success of the program.
Author Disclosure Statement
Dr. Brian Conway has received grants and honorarium from Abbvie, Gilead, Merck & Co. and ViiV.
Funding Information
The workshops discussed in this publication were funded by ViiV Healthcare Ltd. No funding was received for this article.