We spoke to people from four organizations about HIV testing strategies:
Many health authorities across Canada are trying to expand access to HIV testing. Are there any successful HIV testing approaches or practices from your region you'd like to share?
I guess I'd have to say the SPOT Project which started in 2009. The motivation behind SPOT was to increase access to testing for gay men and other men who have sex with men in Montreal. We know testing works well for some people in a clinical setting. The idea behind SPOT was that we might not be reaching other groups of people who don't go to a clinic, who are not as comfortable in a clinical setting or for other reasons don't access testing that way. SPOT allowed us to create a community-based site to offer testing in a more non-medicalized setting. The project is also helping us to reinforce the role that testing can play as a prevention strategy.
One of our innovations was incorporating community workers into the testing team. In Quebec, testing has typically been done only by nurses or doctors. At SPOT we were able to develop a more involved role for the community workers by creating a team approach. The community worker is responsible for the counselling component while the nurses focus mainly on testing. It's the first time that community workers have taken on this role in Quebec.
SPOT allows us to compare this approach to a model where a nurse works alone. We offered both types of interventions and compared them. We were able to demonstrate that the team approach was at least as effective as a nurse working alone and, for some people, it was more effective. This was especially the case for men whose sexual practices place them more at risk, who were more likely to come back for another test after three months when their initial test was provided by the testing team.
We have also been able to compare a community-based setting for testing with a more typical clinical setting. During the first phase of the project, we were able to offer the same intervention at our community site and in two medical clinics. We learned that doing the work in the community setting was at least as good as offering it in the clinic. For some groups of people, including men under 30 and people born outside of Canada, we were able to more easily attract them to the community site.
Some experts see pre- and post-test counselling as a barrier to testing for some clients, especially in the context of routine testing. What are your thoughts?
I would tend to agree that there's a need to have a more nuanced approach to counseling instead of a one size fits all approach. However, I have some concerns if the move to streamline testing is motivated by an idea of counselling as a pesky problem that we just want to go away. This could lead to implementing models of routine testing that we don't necessarily want and that might not work very well.
There are certainly people in the gay community who engage in risky behaviours but are already well-informed about the issues, so there is a case to be made for streamlining counselling for some individuals, especially if we want those people to come back to get re-tested every 3 to 6 months. I think there is value on all sides to see how we can do a better job with counselling. I would like to see this happen in a nuanced way. We also need to break down the assumption that counselling is a problem or something to be avoided.
The SPOT project is allowing us to do research on how to provide better counselling in conjunction with HIV and STI testing. Our main focus for the next phase of research is on evaluating a type of counselling based on motivational interviewing. This approach is more client-focused than standard counselling. The motivational approach involves accompanying people as they identify their own steps and strategies in terms of potential change. We have very preliminary data that suggest motivational interviewing may be more effective than standard counselling and our upcoming research will provide a more complete picture.
Overall, we need to reiterate the value of counselling. At SPOT, what we hear over and over again is that counselling is important. Quite a few people have told us that getting testing at SPOT was the first time they had a chance to have an in-depth talk about personal and sexual health issues with a healthcare provider. This isn't necessarily what everyone in the community needs, but it seems to be the case for a significant proportion of men.
In some regions, health authorities are recommending that the offer of an HIV test be made part of routine health care for all adults. What do you think about this as an option for your community? What are the benefits and drawbacks?
I can see both benefits and drawbacks and I think one of the benefits is the de-stigmatization HIV. We do need to recognize the issue of how hard it can be to bring up the topic of HIV-related risk, both for patient and provider. So as a way to address this, I think routine testing could be a step in the right direction. But if the goal is simply to remove discomfort that healthcare providers may feel when talking about sexual health, then we would be going in the wrong direction.
We also have to keep in mind the bigger picture of what will happen after a diagnosis. Routine testing has the potential to increase diagnoses but then if people are not properly linked to care or their experience of diagnosis is negative, we run the risk of creating new problems.
I think it's helpful to broaden the notion of what we mean by "routine testing." Routine testing has come to refer to systematic testing for the general population, but it may be just as important to strengthen the idea of testing routines as a part of targeted HIV-testing efforts. This would include a community education component that promotes the adoption of testing routines by gay men and MSM whose practices put them at more risk of getting infected. The counselling approaches that we have been developing at SPOT also focus on the capacity of clients to see testing as an important routine in terms of their own health and well-being. For me this is just as important as the more typical ways in which we think about routine testing.
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