community site

Transcription

community site

Key lessons from the SPOT project:
Community‐based HIV and STI testing
for gay and bisexuel men and other MSM in Montreal
Thomas Haig1 , Joanne Otis1,2, Martin Blais2, Mark A. Wainberg3, Robert Rousseau4
and the SPOT study group
1
Chaire de recherche du Canada en éducation à la santé, Université du Québec à Montréal
Département de sexologie, Université du Québec à Montréal
3 Faculty of Medicine, McGill University
4 RÉZO, Montréal
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CATIE Forum 2013: New Science, New Directions in HIV & HCV
Toronto, September 18 2013
A multidisciplinary team
Research team: Joanne Otis (principal investigator), Karine Bertrand, Martin Blais, Bluma Brenner, Gilbert Émond, Gilles Lambert, Ken Monteith, Michel Roger, Robert Rousseau, Mark Wainberg.
Intervention team: Jean Boulanger, Laurence Delisle, Cyril Figureau, Dominique Harvey, Pierrette Héon, Ernesto Hernandez, Émilie Frenette, Isabelle Major, Marie‐Pascale Pichette, Maxime Pouliot, Marc‐André Primeau, Sophie Sansfaçon, Samuel Tozzi.
Coordination and research assistants: Thomas Haig, Michel Martel, Amelie
McFayden, Carl Rodrigue, Benoit Turcotte, Ludivine Veillette‐Bourbeau.
Partners: UQAM; RÉZO; CSSS Jeanne‐Mance; Centre de recherche du CHUM; Centre sida McGill; COCQ‐SIDA; Clinique médicale l’Actuel; Clinique médicale du Quartier Latin; INSPQ; Université Concordia.
Thomas Haig Ph.D., Chaire de recherche du Canada en éducation à la santé, UQAM © 2013
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Today’s presentation
1.
What’s SPOT and why SPOT?
2.
Three avenues for integrating testing and prevention and for strengthening the linkages to care and support:
– SPOT’s community site
– The testing team
– Pre‐ and post‐test counseling
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What’s SPOT?
•
•
HIV and STI testing form gay and bisexual men and other MSM at a community site
Multidisciplinary and intersectoral partenership (RÉZO, CSSS Jeanne‐
Mance, UQAM, McGill, COCQ‐SIDA) www.SPOTtestMONTREAL.com
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What’s SPOT?
1739 participants (phases 1 & 2, 2009‐2012) • Choice of rapid or standard test: 95% of participants have chosen RT
• SPOT community site (n=1029) vs. 2 clinics (l’Actuel, Quartier Latin) (n=155)
• Testing and counselling provided by a nurse working alone or by an intervention team (nurse + community worker) (randomized comparison)
• Standard counseling (SC) based on Quebec government guidelines vs. counseling based on a motivational interviewing (MIC) approach
Phase 1 (2009‐2011): community site + clinics; same intervention at all sites (SC)
Phase 2 (2011‐2012): community site only (MIC)
Phase 3 (2013‐2015): community site (MIC vs. SC) (randomized trial) in progress
 Implementation analysis of community site
 Blood sample analysis (genotyping) to provide a better understanding of the dynamics of HIV transmission within the population
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Why SPOT?
HIV transmission dynamics among MSM in Quebec (2000‐2010)
Unique infections
1 infection leads to 2.7 other infections
25%
40%
1 infection leads to 10 other infections
Brenner B, JID 2011
Testing as a prevention strategy
•
•
•
Increasing the number of HIV+ MSM who are aware of their HIV status could reduce onward transmission (Brenner et al., 2007; Brenner et al., 2011; Pilcher, 2004)
Reaching and retaining MSM for routine and frequent HIV testing has emerged as a key public health strategy (Oster et al., 2011; INSPQ, 2011) :
– Individuals less likely to use other prevention methods may nonetheless be motivated to use routine / frequent HIV testing.
Community based testing in conjunction with the rapid HIV test can
reduce barriers and facilitate access to testing (Fernàndez et al., 2008; Guenter et al., 2008; INSPQ, 2009; Myers et al., 2009; MSSS, 2010; Pedrana et al.,2011; Woods et al., 2010)
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SPOT’s community site
• In close proximity to the gay village
• Integrated sexual health and wellness services:
– Free, anonymous, rapid HIV testing
– STI testing, hepatitis A/B vaccination
– Counseling and consultation
– Referrals to partner clinics and other services (healthcare; psychosocial; community)
• By appointment or walk‐in
• Appointments available on short notice (2 – 3 days)
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Advantages of SPOT’s community site
•
Easily accessible; flexible hours; appointment in a few days:
– Level of satisfaction with time waited (after making an appointment) before seeing someone is 6.52*.
•
Calm, non‐medicalized environment: « there was time to talk ... »
•
On average, participants met at the community site were younger
•
A higher proportion of participants at the community site were born outside Canada
Average level on scale ranging from 1 « Not at all satisfied » to 7« extremely satisfied »
Comparison of clinical and community sites
Variables
Community site
n = 1029
Clinical site
n = 155 OR*
(CI 95%)
Age (35 years or under)
58.9%
43.9%
1.84*
(1.31 – 2.58)
Born outside Canada (yes)
36.5%
26.5%
1.59*
(1.09 – 2.33)
Reassurance about HIV status
97.2%
93.5%
2.57*
(1.20 – 5.48)
Took a risk
77.4%
69.0%
1.48*
(1.01 – 2.16)
Partner took a risk
18.5%
27.1%
0.56*
(0.38 – 0.83)
Broken condom
15.8%
8.4%
1.92*
(1.05 – 3.49)
Previously tested for HIV (yes)
88.5%
92.9%
0.65
0.34 – 1.27)
Unprotected sex with HIV+ or HIV? partner (last 3 months) (yes)
36.6%
40.3%
1.05
(0.66 – 1.68)
Reason for getting tested: *Adjusted odds ratio controlled for age, country of birth, sexual orientation, income, education, and extent of gay social network. 10
The testing team
• Testing services at SPOT are provided by a testing team consisting of:
– A community worke (responsible for pre‐ and post‐test counseling)
– A nurse (responsible for testing)
• The inclusion of community workers enhances the intervention team and offers an additional way to introduce discussion of gay realities and contexts and give expression to community experiences
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The testing team adds value*
Variable : Came back for another HIV test 3 months later
Testing site
Community
Clinical
n = 1029
n = 155
22.1%
23.9%
Staff
OR**
(CI 95%)
Testing team
n = 599
Nurse only
n = 585
OR
(CI 95%)
0.94
(0.63‐1.42)
24.7%
19.9%
1.32*
(1.00‐1.75)
* Intervention team consisting of a community worker and a nurse
** Adjusted odds ratio controlled for age, country of birth, sexual orientation, income, education, and extent
of gay social network. Thomas Haig Ph.D., Chaire de recherche du Canada en éducation à la santé, UQAM © 2013
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Results – univariate analysis
Unprotected anal intercourse (UAI) in the last three months
Variables
Repeat testers‡
(n=264)
No repeat test
(n=920)
OR
CI 95%
UAI with
HIV? or HIV+ partner
At least once
40.7%
28.7%***
1.70
1.28‐2.26
Intentional UAI with
HIV? or HIV+ partner
At least once
21.2%
14.9%*
1.53
1.08‐2.17
*** p < 0,0001 ** p < 0,001 * p < 0,05
‡ Came back for another test 3 months later
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Pre‐ and post‐test counseling
• The linkage of virological, behavioural, and pyschosocial data in the context of the SPOT project has served to orient intervention development and clarify the focus of counselling. This analysis has shown that: – testing habits are the main factor influencing the extent of onward transmission
– emphasis should be placed on encouraging and facilitating routine and frequent HIV testing among sexually active MSM.
• The counseling provided in conjunction with testing offers a key opportunity to explore preventive practices and testing habits. • Research suggests motivational interviewing approaches can increase the effectiveness of counseling (Suarez & Miller, 2001; Metcalf et al., 2005). Thomas Haig Ph.D., Chaire de recherche du Canada en éducation à la santé, UQAM © 2013
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Motivational interviewing counseling • MIC: brief intervention (15‐20 minutes) that puts participants at the centre of the conversation, enabling them to identify their own focal points for change, objectives, and strategies
• Less focused on transmitting information and advice than standard counseling (SC)
He’s probably negative like me
Sex on the brain
How do I bring it up?
A bit too much partying
He could be Mr. Right
Fed up with being careful
I didn’t see it coming…
It’s not worth the trouble
Counseling types: preliminary comparison
Unprotected anal sex with an HIV+ or HIV? partner in the following 3 months
among SPOT participants (2009‐2012)
40
35
35.1
28.9
30
25
18.9
20
15
10.6
10
5
0
T0
T1
Standard counseling(SC); p=0.06
Based on Quebec guidelines
T0
T1
Motivational interviewing counseling (MIC); p=0.04
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How implementation has progressed at SPOT
100
90
Overall
80
Pre‐test
70
Testing
60
Post‐test
50
P1
P2
P3
P4
P5
P6
P7
P8
P9
P10
P11
P12
Period 1 (P1) : July to October 2009 / Period 2 (P2) : November 2009 to January 2010
Standard Period 3 (P3) : February to April 2010 / Period 4 (P4) : May to July 2010
counseling
Period 5 (P5) : Augus to October 2010 / Period 6 (P6) : November 2010 to January 2011
Period 7 (P7) : February to April 2011
Motivational
Period 8 (P8) : May to July 2011 / Period 9 (P9) : August to October 2011
interviewing
Period 10 (P10) : November 2011 to January 2012 / Period 11 (P11) : February to April 2012
counseling
Period 12 (P12) : May to July 2012
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MIC: implementation challenges
• Counseling based on motivational interviewing (MIC) may have more impact in terms of prevention than standard counseling (SC), but the superiority of MIC remains to be demonstrated.
• MIC is more difficult to use in situations where:
– Participants do not take risks or have taken a lot of risks;
– Participant have mental health difficulties (e.g. anxiety).
• CEM requires significantly more investment in training and clinical supervision than CS.
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Next steps
• A process is currently underway that will see SPOT become an ongoing service and allow the community‐based site, infrastructure, and testing model to be maintained. • Upcoming communication strategies will emphasize the promotion of routine and frequent testing for sexually active gay men and other MSM (in particular those who have multiple partners, those who are under 30 years of age , and those who have not been tested in more than a year). • A randomized trial to compare the effectiveness of motivational interviewing counseling with standard counseling is now underway (2013‐
2015)
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Acknowledgements
RÉZO: Cyril Figureau, Maxime Pouliot, Marc‐André Primeau, Thierry Sauvain, Samuel Tozzi et les
bénévoles à l’accueil
CSSS Jeanne‐Mance: Jean Boulanger, Laurence Delisle, Dominique Harvey, Pierrette Héon,
Ernesto Hernandez, Émilie Frenette, Isabelle Major, Marie‐Pascale Pichette, Sophie Sansfaçon
UQAM: Mélina Bernier, Marie‐Ève Girard, Michel Martel, Amélie McFayden,, Carl Rodrigue, Claire
Thiboutot, Benoit Turcotte, Ludivine Veillette‐Bourbeau
Lady Davis Institute, Jewish General Hospital: Bonnie Spira, Frédéric Ohnona, Daniela Moise
Réseau SIDA/MI: Anne Vassal, Julie Belley, Sonia Duquette, Mario Legault
Clinique médicale L’Actuel: Dr. Réjean Thomas, Dr. Benoît Trottier, Dr. Sylvie Vézina, Line Provost,
Steve Girard, Catherine Cartier, Blanca Gomez, Isabelle Benoît
Clinique médicale Quartier Latin: Éric Lefebvre, Dr. Pierre Côté, Dr. Jean‐Guy Baril, Lucie Height
INSPQ : Évelyne Fleury
Motivational interviewing consultants: Patrick Berthiaume, Karine Bertrand, Julie Brisette, Rick
Julien, Scott Simpson
bioLytical : INSTITM rapid HIV test kits
Special thanks to all the men from the community who have participated in the SPOT project
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Partners
Funding for SPOT has been provided by: Direction de santé publique de Montréal; Instituts
de recherche en santé du Canada (IRSC); Ministère de santé et des services sociaux du
Québec (MSSS); Réseau canadien pour les essais VIH des IRSC (CTNPT 002); Réseau sida et
maladies infectieuses ‐ Fonds de la recherche en santé du Québec (FRSQ).
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community site

Transcription

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