Vancouver HIV/AIDS
Care Co-ordinating Committee
Public Sections
Documents: Environment Report 1999-2002
This is a companion document to the Strategic Plan and a work in progress; this version March 31, 2000
HEALTH SERVICES
Access to multidisciplinary community and acute health care
services has been a cornerstone of Canada’s health care
system. In the current context of regionalization, many service
models are being re-examined to ensure that service is being
delivered as effectively and economically as possible. What
follows is a general summary of such services for the Vancouver
area, moving from community to acute to palliative care.
Community Health Centres, Clinics and Outreach
Since the reorganization of health services in January 1996, a
model of community health centres has been introduced by the
Vancouver/Richmond Health Board. A community health centre is a
user-friendly facility that provides local residents with a range
of health services and an overall approach reflecting the
perspective of the public. Programs are integrated whenever
possible to simplify their access and use by the community and
are delivered by multidisciplinary teams. The rationale behind
the implementation of community health centres is to improve
access, to integrate service and administration, to reform
primary care, to use a population health approach and to involve
the consumer and the public.
Downtown Community Health Centre
412 East Cordova
255-3151
Monday to Friday, 8:30 am to 4:30 pm; no appointmentsPrimary care, methadone, HIV care, dental care, pharmacy, food store, TB clinic, dietitian, money management and assistance with access to social programs; restricted to individuals residing in the Downtown Eastside or who are homeless; case management and advocacy service is also available one day per week with an AIDS Vancouver staff person
Downtown South Community Health Centre
1065 Seymour Street
659-1144
Tuesday to Friday, noon to 7:30 pm; Saturday, 10:00 am to 6:00 pm; appointment times available
Primary care, addiction medicine, HIV care, alcohol and addiction counselling, assistance with access to social programs, dietitian, psychiatric services, needle exchange and the Vanguard Project; serves clients residing in the Downtown South, West End, or who are gay, lesbian, bisexual or transgendered, homeless or street kids
West Side Community Health Centre
2110 West 43rd Avenue
261-6366Primary care; this is a new centre and is currently working on establishing its programs
In addition, there are several clinics in the city that provide services to groups at risk.
IDC (The John Ruedy Immunodeficiency Clinic)
5th Floor, St. Paul’s Hospital
Monday to Friday, 8:00 am to 4:00 pmPharmacy counselling, nutritional counselling, social work support, nursing assessment and education, physiotherapy, pentamidine administration and laboratory; team members include medical experts in infectious disease, antiretroviral therapy, family practice medicine, dermatology, oral disease and gastroenterology; connections to off-site ophthalmology, psychiatry, respiratory and neurology services are maintained; IDC plays a leading role in the drug research program, working closely with the BC Centre for Excellence in HIV/AIDS and the Canadian HIV Trials Network; annual visits number more than 17,000
Bridge Health Clinic
3rd Floor, Mount St. Joseph Hospital
3080 Prince Edward Street
877-8550
Monday to Friday, 1:00 pm to 4:00 pm; Wednesday, 1:00 pm to 5:30 pmPrimary care, family planning, HIV care, methadone, well baby services, immunizations and health counselling; free clinic for refugees and new immigrants
Vancouver Native Health
449 East Hastings Street
255-9976
Monday and Tuesday, 10:00 am to 8:00 pm; Tuesday and Wednesday, 9:30 am to 8:30 pm; Friday to Sunday, 9:30 am to 5:00 pm; no appointmentsPrimary care, HIV care, methadone, blood testing, etc.
Monday Health Project
1065 Seymour Street
Monday, 1:00 pm to 5:00 pmMultidisciplinary clinic for LGBT people
1. The AIDS Prevention Street Nurse Program
The goal of the AIDS Prevention Street Nurse Program is to reduce the transmission of STDs and HIV among marginalized persons. The outreach program focuses on HIV/STD education, testing, diagnosis and management. Street nurses also provide support and advocacy, crisis counselling, first aid, harm reduction education, counselling and support, and medical and social service referrals.
The program currently has two storefront clinics. The Main Street Clinic serves a target group made up mostly of street-involved persons, at risk through injection drug use and sex trade work. The Bute Street Clinic serves gay, lesbian, bisexual and transgendered populations. Sessional physicians provide part-time services at the two storefront clinics.
Street nurses, in partnership with several agencies, provide education and clinic services to street-involved youth and adults at a variety of outreach sites, including jails, detox centres, hotels, residences, drop-ins, community agencies and on the street.
The total number of client contacts in 1998 was 48,484.
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2. CHRP Findings on Clinic Use
The following charts show CHRP’s findings on the use of hospital and community-based health clinics. The two categories compared are MSM and male IDUs. Similar data for female IDUs will be reported in the near future for the entire CHRP sample.
For both tables above the numbers of participants are as follows:
| Stage Group | I & II | III | IV |
| MSM | n=38 | n=35 | n=56 |
| Male IDU | n=26 | n=37 | n=31 |
As HIV progresses, the percentage of MSM who report a visit to a hospital clinic increases while visits to community clinics decrease. The opposite happens for male IDUs; there is an increase in community clinic visits in Stages III and IV, with a corresponding decrease in hospital clinic visits.
Community-based organizations recognize there is a pressing need to develop better systems for case management in partnership with clients, the professional community and government. Integrated case management focuses on the management of clients’ needs across provider and agency lines to link clients to the appropriate level of resources. Case management is a partnership between the manager and the client; it entails the continual assessment and follow up of the client’s needs. Case management is particularly important for clients who have multiple problems, such as HIV/AIDS and substance abuse or psychiatric illness, because they need to have access to many organizations and resources.
Case management service is currently available through AIDS
Vancouver’s support service department, the
Vancouver/Richmond Health Board (particularly for those requiring
home care and allied support, with some clinic staff), the
Vancouver Native Health Society, DAMS, and Greater Vancouver
Mental Health Services, including Strathcona Mental Health’s
HIV Team and the Assertive Care Team.
Access to physician services is essential for the management and prevention of HIV infection. Through early identification of HIV infection and treatment with appropriate medications, viral loads can be reduced to undetectable levels with subsequent enhanced health for the individual and decreased risk of transmission to others. For individuals with AIDS-defining illnesses, access to physician care is often complex, especially when AIDS affects more than one system and various specialists are required. Access to palliative care is equally important for AIDS patients with end-stage disease. In addition to treatment of HIV/AIDS, access to physician services for addictions, including methadone treatment, forms part of the spectrum of harm reduction services aimed at decreasing the spread of HIV and the harm of addiction to the individual.
In Vancouver, the most common barriers to accessing physician care include but are not limited to poverty (including lack of transportation and telephones), social isolation, language and cultural barriers. Homophobia and heterosexism within the health care system present additional barriers, on both an individual care provider level and on a more systemic level. Limited availability of physicians providing HIV/AIDS-specific services and methadone treatment further compromises access; for someone requiring specialist care for the medical complications of HIV, several different physicians may be involved in the person’s care. It is difficult for even the most sophisticated consumers of health care to negotiate their way through the maze of private fee-for-service offices, public clinics and hospitals. This complex arrangement of physician services is particularly challenging for anyone unfamiliar with the health care system; access to care is even more compromised when any of the other barriers mentioned above co-exist with confusion about how to move through the system.
Community clinics are attempting to overcome the barriers to
accessing physician care through promoting the one-stop-shop
model of care, where harm reduction modalities and other
prevention services are made available at one site along with
physician care. In the community clinic setting, payment of
physicians through salary or sessions eliminates the barrier of
fee-for-service; clients have the additional benefit of a
multidisciplinary team approach to their care. Counsellors with
cultural competence can be of great assistance to physicians in
helping the clients to understand and accept the treatment
regimens and life-style choices that will optimize their health
and reduce the risk of transmission of HIV to others. It is also
easier to provide interpretation in a variety of languages in a
clinic setting than in a private office, thus addressing the
barrier of language. By being situated in their own neighborhood,
populations served by a community clinic can much more readily
access the physician services they need for prevention and
treatment of HIV. Neighbourhoods with the highest concentration
of disadvantaged populations living in poverty and social or
cultural isolation are natural settings to build upon the
community clinic model and so benefit those people with HIV who
face the most barriers to physician care.
1. Access to Primary Care Physicians
Private practitioners
- The College of Physicians and Surgeons of BC provides three references by geographic area, gender and language
- The BCCDC lists physicians by language who accept HIV/AIDS patients
Hospital-based clinics
- Oak Tree Clinic
- St. Paul’s Hospital IDC
Community-based clinics (see above)
2. Services Provided by Primary Care Physicians
General medical care
- Regular check-ups
- Blood work
- Medications
- Completing forms for disability benefits, EI medical benefits, MHR, etc.
- Referral for outpatient specialist care (8% of CHRP participants visited a specialist at least once in the two weeks prior to being interviewed)
- Admission to hospital for inpatient care
Inpatient care (primary care physician or admitting physician)
Emergency care
3. Cost of Care
Permanent residents of BC with PHN and valid Medical Services Plan
- Qualify for medical services plan after three months in BC
- Qualify for hospital care without charge
- Basic medical services plan covers:
- Full cost of care by medical doctors
- Physiotherapist, registered massage therapist, chiropractor, naturopath (12 visits per year; there is a user fee of $10 per visit; if the practitioner is not working under the medical plan, then the client must pay the full cost of the visit and will only be reimbursed a portion by MSP)
- Optometrist (once every two years)
Visitors, tourists, non-residents
- Will be charged for physician and hospital services
- Health insurance for travellers may have restrictions such as no coverage for pre-existing conditions
- Hospitals vary in their daily charge for non-residents
Refugee claimants
- May qualify for some physician and hospital services, including laboratory testing and medications, through Interim Federal Health (IFH)
- Immigration officer at port of entry or at interview when claim is made will determine eligibility for IFH
- Restrictions apply to those eligible for IFH, and prior approval must be sought for medications not on the BC Pharmacare formulary and for tests and care not considered emergency or essential as per IFH guidelines
Community Clinics
- Costs associated with primary care at most community clinics are absorbed by block funding and salaried or sessional physicians
- Hospital care and many of the tests and medications required for HIV/AIDS care are commonly not provided by community clinics
Medications,
Including Antiretroviral Therapies
1. CHRP Findings on Antiretroviral Use
The graph below shows some of CHRP’s preliminary findings on antiretroviral use, broken down into gender and transmission groups. It shows what percentage of each group (in stage IV) are using antiretrovirals. Approximately 9% of MSM are not taking any antiretrovirals, compared to 46% of male IDUs and 67% of female IDUs. Sixty-seven percent of MSM are taking a three drug combination, while 32% of male IDUs are taking three drugs. No female IDUs in stage IV are taking three drug therapy, though the number in the sample (nine) is very small.
The numbers of each group are small because, at this time, CHRP has not been able to stage everyone in the study. Staging of participants is done by using CD4 count and some clinical diagnoses. Some participants don’t know or can’t remember their CD4 count while others may decline to provide this information. The group of people who do not know their CD4 count is potentially very interesting. Are these people being tested and choosing not to find out the results? Are they possibly forgetting the results, or are they people who have decided not to get regular testing or who are having difficulties accessing testing?
It is critical that caregiving systems are examined closely to
develop a better understanding of why male and female injection
drug users are not accessing antiretroviral medications. It is
vital that new treatment systems that are developed which improve
realistic access to antiretrovirals for this group.
Methadone is used in Canada for the treatment of opiate users. It is a long-acting, synthetic opiate agonist with good oral efficacy. Oral methadone has proven to be effective in suppressing opiate withdrawal following cessation of drug consumption. Methadone is also prescribed daily, over months or years, to some people, with the expectation of reducing opiate use and associated harm. This is termed "methadone maintenance treatment" within the medical community.
By 1994, more than half of all methadone patients in Canada were located in British Columbia, the majority in the Vancouver area.
While methadone is not the solution to the growing epidemics among mixed injection drug users in Vancouver (those using heroine in conjunction with other substances), there is strong evidence that methadone programs can assist many heroine users in reducing their injection use.
In British Columbia, methadone can only be prescribed by physicians who are specifically licensed to do so through the BC College of Physicians and Surgeons, and the number of patients for whom a licensed physician may prescribe methadone is restricted.
Until recently, access to methadone has been extremely limited, particularly in the Downtown Eastside, where until mid-1996 there was only one methadone-licensed local physician. By 1997, some clinic physicians had obtained methadone licenses and the number of methadone spaces in the Downtown Eastside had increased to about 150. While the Ministry of Health, in conjunction with the BC College of Physicians and Surgeons, has increased the number of physicians authorized to prescribe methadone, more action is still needed in this area.
For offenders in provincial and federal correctional facilities in British Columbia, there is access to a methadone maintenance intervention and treatment program. This program encourages the offenders to participate in substance abuse counseling and provides extensive support. Once the offenders are released into the community, the correctional staff liaise with the community support network established by the BC College of Physicians and Surgeons.
The relative absence of local community services to support addicted people has contributed to some reluctance among agencies and residents to support expanded methadone availability, particularly in the Downtown Eastside. Residents and users have also expressed concerns about diversion of methadone to the streets and the pharmacological effects of methadone itself. Many have pointed out that methadone is not tolerated or suited for all, which is one reason why it can’t be the only solution.
Canada’s National Action Plan on HIV, AIDS and Injection Drug Use calls for improving access to methadone treatment by:
- Changing legislation and regulations to allow physicians to prescribe methadone like any other drug, making methadone more accessible
- Making appropriate training available to physicians to encourage their involvement in providing methadone treatment to injection drug users
- Reducing and eliminating other barriers to being on methadone, and basing decisions regarding methadone-carrying privileges on reliable and responsible behaviour of the individual
- Creating a central coordinating agency to link users and doctors at the local level, so that users know how to access methadone services
- Communicating the results of research on the effects of methadone on pregnancy and breastfeeding to practitioners and the general public, especially women
- Investigating other alternative drug therapies beyond methadone, such as buprenorphine, naltrexone and levo-alphacetylmethadol (LAAM)
In Vancouver, there is a need to:
- Provide coordinated, quality-controlled methadone programming with evaluation and accountability in the Downtown Eastside and throughout the Vancouver area
- Expand the capacity of the Vancouver downtown methadone system to serve opiate-addicted people
- Provide methadone programming within settings that also offer an array of basic, lifeskills, recreational and medial supports
Dental Care
Good preventative dental care is an important part of a
complete health program for people living with HIV/AIDS. However,
given the fact that dental care is not well integrated into our
overall health care system, cost barriers can be large and at
times insurmountable for persons living on low incomes. Dental
care in the Vancouver area is largely available through dentists
in private practice. People living with HIV/AIDS, who are either
employed or living on a private disability plan, may have the
costs of such services covered through a dental plan. Those
without access to such a plan must pay the full cost of dental
care. Persons receiving income assistance are eligible for
emergency dental service.
1. Services Available
- Individuals receiving benefits from the Ministry of Human Resources are eligible for some dental coverage, generally emergency only
- There is a dental clinic available through the Downtown Community Health Centre for Downtown Eastside area residents only
- IDC, an outpatient clinic at St. Paul’s Hospital, provides preventive and ongoing dental care
- Some clients without the ability to pay the cost of dental care are able to access dental services through the University of British Columbia School of Dentistry clinic, which functions as part of the teaching program
- There is a high risk dental clinic at Vancouver General Hospital
2. CHRP Findings on Dental Care
The above graph shows a statistically significant difference
(p<0.001) between IDUs and non-IDUs who accessed dental care
in the past year. CHRP data show that 45% of IDUs have not
accessed dental care in at least one year.
1. St. Paul’s Hospital
St. Paul’s Hospital has played a major role in the provision of care to individuals with HIV/AIDS since the early 1980s. In February 1997, an 18-bed HIV/AIDS ward was opened and staffed by a designated multidisciplinary team of physicians (an internal medicine specialist and two clinical associates), nurses, pharmacists, a clinical nurse specialist, a dietitian and social workers. There are four social workers: one assigned to the HIV/AIDS ward, another who sees off-service patients and two aboriginal social workers who work half-time in the hospital and half-time in the community following aboriginal clients. The average daily inpatient census is 30. Patients who are not admitted to the HIV/AIDS unit are cared for on other units in the hospital (e.g., palliative care, medical units).
Increasing numbers of injection drug users are being admitted to the hospital. In 1994 there were an average of 43 IDU discharges per month and in the fiscal year 1997-98 an average of 92 IDU discharges per month. Data from the last fiscal year indicate 46% of these IDU patients are HIV-positive and approximately half of all IDUs are admitted for problems directly related to the use of injection drugs (e.g., abscesses, sepsis, endocarditis, etc.). The IDU Consult Team, consisting of an addiction physician and the clinical nurse specialist for HIV/AIDS, receives medical referrals regarding hospital management of care (i.e., drug withdrawal, pain control, HIV prevention, education and support) and discharge planning.
The AIDS Care Team is a multidisciplinary team with representatives from the hospital and the community. The team reviews current inpatients, discharges and deaths on a weekly basis with the goal of improving the continuity and coordination of care. In addition to patient care, research on new therapies is conducted through St. Paul’s in conjunction with the Canadian HIV Trials Network and the BC Centre for Excellence in HIV/AIDS.
2. Vancouver General Hospital
Vancouver General Hospital has an HIV/AIDS clinical care team that is composed of one social worker and four doctors working rotating shifts to ensure that Monday to Friday there is always an on-call HIV/AIDS specialist. The team is involved in consultations, assessments, interventions and treatment with each patient who is referred to them. Referrals come from social workers, physicians and other health care workers, both inside the hospital and from the community. This previously informal information exchange between hospital and community has been formalized in weekly community meetings that facilitate the timely exchange of information between hospital-based and community-based service providers.
Given the large number of injection drug users who are seen by the HIV/AIDS clinical care team at the Vancouver General Hospital (currently estimated at 85% to 90% of all referrals), the clinical care team works closely with the Chemical Dependency Resource Team (CDRT). Working in close collaboration with CDRT enables the HIV/AIDS team to provide appropriate in-hospital care and community referrals for both patients’ HIV/AIDS status and their substance abuse. In addition to the direct medical care provided by the hospital, patients and their families have access to counseling, education and social work services to ensure awareness of appropriate community resources and discharge planning options.
3. CHRP Findings on Emergency Room Use
The above graph shows a statistically significant difference (p=0.040) between IDUs in Stage IV and non-IDUs in Stage IV who access emergency room services. CHRP asked, "In the past two weeks, did you go to a hospital emergency room for medical care?" Nine percent of non-IDUs answered yes, compared to 20% of IDUs.
Thirteen percent of CHRP participants visited an emergency
room at least once in the two weeks prior to being interviewed.
Seven percent of CHRP participants were patients in a hospital
for at least one night in the two weeks prior to the interview.
All the services of home-based care uphold the individuals’ dignity and the right to remain at home as long as possible with full participation in their own care. Waiting lists continue to grow and organizations struggle to serve as many people as possible with limited resources. The epidemic curve currently allows agencies to serve only those most in need, often because of poverty and other social issues, with the result that those living with HIV/AIDS who are less ill cannot access any but the most rudimentary services and support. The implication for the next wave of very ill people, both after lengthy infection periods and failure of antiretroviral therapy, is that these services are going to be flooded with eligible applicants who cannot be served.
1. Continuing Care
The Vancouver/Richmond Health Board is responsible for a range of home-based care and support. Case managers determine the level of home support required for those who are ill at home and unable to care for themselves adequately. Reassessments are conducted when the level of need changes. Home supports services can include basic care, housecleaning, laundry and other assistance with daily living tasks. Increased pressure has been placed on the home care system as patients are discharged earlier from acute care, but funding has not kept pace with needs.
Home care nursing support is available from local health units. Earlier in the epidemic, the Burrard Unit developed great expertise in providing home care nursing support for those living with HIV/AIDS. More recently, North Unit nurses have been carrying an increasing proportion of the HIV/AIDS case load. Current issues include people living with HIV in single room occupancy hotels and other sub-standard or unstable housing situations which make it difficult to provide effective home care nursing.
Home care nurses are able to assist with medication management, wound care and dressings, etc.
2. Other Care at Home
Care and visit teams, such as those provided by AIDS Vancouver, Healing Our Spirit and Friends for Life, are composed of volunteers and may supplement services already going into the home. They offer quality, reliable support that includes companionship, practical assistance and personal care but does not replace the role of professional homemakers. They also make referrals and act as liaison with various other support programs.
Thirteen percent of CHRP participants received help at home from an agency, group, organization or individual at least once in the two weeks prior to being interviewed. This help could be for medical problems, personal care, housework or other needed services.
3. Day Programs
The Dr. Peter Centre Day Program provides a unique health care service to individuals living with HIV/AIDS who face life threatening health deterioration. The focus is on fostering the participants’ abilities to manage their own care to the greatest extent possible. Programs and services include hot meals, nursing support and health education, individual and group therapy, nutrition consultation and education, recreation and exercise, socialization, complementary therapies, primary worker support and individual care plans, transportation assistance and respite and support for partners, family members and friends.
The Vancouver Native Health Society operates a storefront drop-in program which offers a range of support services, including food programs, nursing support and physician care, medication management, outreach to single room occupancy hotels and other residences in the Downtown Eastside neighborhood, and a range of support groups and other services. The focus includes reaching out to marginalized, often multiply diagnosed Downtown Eastside residents who otherwise may face difficulties in accessing the level of care and support they require.
Friends for Life, established in 1983, provides more than 50 health and wellness programs without charge to its members. The goal of all programs is to help members cope with the anxiety and stress of living with a life threatening illness while improving their overall quality of life. Among the programs available are support groups, one-on-one counseling, a resource library, workshops on a wide variety of topics, massage therapies, social support and meals.
4. CHRP Findings on Home Care Use
The following graph shows the percentage of respondents who said they had received paid care and support at home in the previous two weeks. Specific types of care include nursing, cleaning and laundry and homemaker services.
For the above table, numbers of participants
are as follows:
| Stage Group | I & II | III | IV |
| MSM | n=38 | n=35 | n=56 |
| Male IDU | n=26 | n=37 | n=31 |
The number of persons receiving paid care and support at home in stage IV is much higher for MSM than for male IDUs. This might be directly tied to housing issues. It may be much more difficult to access home care and support if you live in a non-stable housing environment. More IDUs than MSM live in what might be considered non-stable housing.
5. Residential Care
Residential care and hospice service for persons living with HIV/AIDS in Vancouver is currently offered through May’s Place, St. James Community Services Society, and by the Dr. Peter Centre Residence. In addition, referrals are sometimes made to long-term care facilities for individuals living with HIV who require 24-hour care and support. Education programs for staff in these facilities have been designed by the Department of Education and Health Care Evaluation, BC Centre for Excellence in HIV/AIDS, in order to assist facility staff with skills needed to provide effective and safe care.
However, a significant number of people living with HIV/AIDS have been kept in acute care facilities considerably longer than strictly required while awaiting placement in appropriate long-term care facilities.
Three percent of CHRP participants were patients in a
residential care facility, nursing home or hospice for at least
one night in the two weeks prior to being interviewed.
Medical equipment such as wheelchairs, bath benches and electric scooters are available to persons on BC Benefits who are able to establish medical need for such equipment. Additional assistance in this area is available from occupational therapists who work out of local health units. Those on private disability plans may be able to recover part of the costs associated with such equipment.
For those who are ineligible under the above programs, there are a number of community agencies who provide loans of medical equipment. The Red Cross has a large medical equipment bank, as does AIDS Vancouver’s medical equipment loan program.
Five percent of CHRP participants had to buy, rent or replace
special medical equipment, such as eyeglasses, canes or
nebulizers, in the two weeks prior to being interviewed.
Dr. Michael O’Shaughnessy, Centre Director for the BC Centre of Excellence in HIV/AIDS, has predicted that malnutrition and wasting will become the leading causes of death in the current AIDS population in British Columbia (April, 1999).
Opportunistic infections associated with HIV/AIDS often render a person unable to shop for, prepare or eat wholesome meals. The requirements of highly active antiretroviral therapy, poverty, limited facilities and the personal skill level of many HIV-positive individuals further complicate people’s abilities to meet their nutritional needs. The consequence is weight loss and increased risk of compromise to the immune system.
Maintaining healthy nutrition levels, therefore, is vital to the health and well-being of people living with HIV/AIDS. Many agencies and departments of health are now providing more than basic food services. People living with HIV/AIDS can obtain nutritional counseling through their physicians and various clinics or agencies on an outreach basis.
Several agencies provide free or low-cost meals to people living in poverty, although few have the capacity to provide more than very basic meals. Most of the agencies are just beginning to look at the unique requirements of the HIV/AIDS population. For example, the special diets required by people living with HIV/AIDS because of the disease and/or medication are beyond the scope of most agencies given their limited resources. Similarly, line ups and the lack of home delivery can preclude some people in the end stages of the disease from accessing service.
One agency, A Loving Spoonful, delivers a week’s supply of free, nutritious, frozen meals, fresh fruit and bread to people living with HIV/AIDS who have been referred by their physician. Eligibility for service is based on a medical assessment. Loans of microwave ovens and small refrigerators can also be arranged. The current program does not provide the full, recommended daily allowance of nutrients, although recipes are tailored for HIV disease and HAART issues.
Another organization, Food for Thought, provides nutritious meals and an opportunity for social support to persons living with HIV/AIDS in the Downtown Eastside neighbourhood.
Grocery programs, which supplement the food and personal
hygiene items that individuals on limited incomes are able to
purchase, are a necessity for many people living with HIV/AIDS.
For example, in 1998 more than 700 people living with HIV/AIDS
used either the AIDS Grocery or Vancouver Native Health Food Bank
each week.
1. CHRP Findings on Food Program Use
The above chart refers to participants who said they had
received help obtaining food in the previous two weeks. These
food services may include meals served away from home, prepared
meals delivered to the home, or groceries (for example, from a
food bank). As the chart shows, there is a statistically
significant difference (p<0.001) between IDUs and non-IDUs who
use food services. On average, over 71% of CHRP participants
receive help in obtaining food.
Palliative care, as a philosophy of care, is the combination of active and compassionate therapies intended to comfort and support individuals and families who are living with a life-threatening illness. Palliative care strives to meet physical, psychological, social and spiritual expectations and needs, while remaining sensitive to personal, cultural and religious values, beliefs and practices.
Palliative care is planned and delivered through the collaborative efforts of an interdisciplinary team including the individual, their family of choice, caregivers, and service providers. Palliative care is provided in the home, in free-standing hospices, in hospitals with or without a designated palliative care unit, and in long-term care facilities.
Respite care offers short-term elective admissions to facilities with designated respite beds. The benefits are two fold: the family and caregivers are given a rest from caregiving and the client’s symptom management and care needs can be reviewed by the palliative care team. Planned respite admissions allow clients to remain at home with greater support.
Palliative care services are available in the community through home nursing care and consultation with the Vancouver Home Hospice Program. Palliative care physicians are on-call 24 hours a day. St. Paul’s Hospital and Vancouver Hospital have designated palliative care units. These units serve as the tertiary care areas for palliative care. In other words, there are those situations that cannot be adequately managed in a home or home-like environment and admission to a special unit is required. St. James Community Services provides palliative services through May’s Place on Powell Street. May’s provides a place of comfort, physical and spiritual, for many residents of the Downtown Eastside. Cottage Hospice is scheduled to open early in 1999. The Dr. Peter Foundation opened its Day Centre in 1997 followed by the Residence in 1998. Both programs are in St. Paul’s Hospital Comox building until a permanent site is constructed. Although not called a hospice, the residents of the Dr. Peter Residence do receive palliative care services as needed. Additional professional nursing care is provided through the Health Board’s community program and the Vancouver Home Hospice physicians make home visits.
Additional knowledge and skills are needed by caregivers in HIV palliative care to understand and meet the needs of the growing numbers of injection drug users who are dying in the city. Health Canada is sponsoring a pilot project to address these issues. Local organizations need to support these endeavours by collaborating in the project.
Although palliative care has been located in long-term care facilities, this concept is not universal for the elderly. Persons living and dying with AIDS who have needed placement prior to their imminent death have not been accepted into traditional continuing care intermediate or long-term facilities. The reasons for this are vague, oblique and biased. This is one area that the community needs to re-examine, particularly because HIV disease is a more chronic condition now than it was fifteen years ago.
Caregivers are not well prepared to deliver palliative care in the prison systems. Again, the reasons for this are unclear and need to be openly addressed.
Problems still faced by clients who wish to remain at home are:
- Having to pay for drugs that are received free in hospital
- Having to pay for dressings and other supplies that are supplied free in hospital
- Having to go into hospital because of insufficient nursing and ancillary supports after hours and on weekends
- Lack of compensation for family or friends who provide core care at home who have to leave employment
- Lack of coordination between hospitals, family physicians and care providers
- Substandard care for people living in SROs
The Vancouver/Richmond Palliative Care Coordinating Group is meeting with the Vancouver/Richmond Health Board to develop a regional plan for palliative care. The BC Hospice Palliative Care Association is a partner in an HIV/IDU palliative care project.
Psychiatric complications may develop as a result of HIV/AIDS or mental illness may be present prior to the person contracting HIV. There are also a number of people who have multiple diagnoses including psychiatric illness. The psychiatric complications of HIV disease include depression, adjustment disorders, anxiety or panic disorders, delirium, mania, psychosis and organic brain disease or dementia. These conditions are common, particularly with HIV disease progression, but are treatable. The causes of these psychiatric symptoms include medication side effects, HIV-related central nervous system disease, the cumulative effect of multiple stressors and losses, characterological or genetic predisposition of the person and substance abuse.
There is increasing evidence that people with serious mental illness living in large urban centres represent a group vulnerable to contracting HIV. The reasons for this are multifaceted and relate to the nature of mental illness. They include cognitive deficits and psychopathology, ambivalence, discomfort in traditional health care settings, vulnerability to sexual victimization and self-medication with drugs and alcohol. Clients with chronic mental illness need special education, such as harm reduction and follow-up (often outreach) services. Historically, clinic-based mental health services have been under-utilized by this population
At present, there are insufficient psychiatric services for people with HIV/AIDS and serious mental illness in Vancouver, although there are some specialized services in the Downtown Eastside. Mental health services are offered through Greater Vancouver Mental Health Community Teams and various specialized programs. Assessment services are available through Psychiatric Assessment Unit at Vancouver General Hospital and emergency departments at acute care facilities.
Currently, the HIV/AIDS Psychiatry Outpatient Program at St. Paul’s Hospital attempts to meet needs for assessment (including neuropsychiatric), short-term intervention and ongoing treatment for individuals with mental health complications arising from HIV. However, because of limited staffing and resources, it is not capable of providing a higher volume of patient services, as requested by the community.
There are limited resources for people with less severe mental
health difficulties or those requiring individualized support
from a private psychiatrist. There are insufficient psychiatric
services for people with HIV/AIDS and serious mental illness or
less severe mental health difficulties. Services between provider
agencies are poorly coordinated and waiting lists are often long.
The lack of appropriate and coordinated service delivery between
agencies and organizations has the biggest impact on those
clients with multiple diagnoses.
1. Multiple Diagnoses
Clients with multiple diagnoses include those who have a psychiatric disability, chemical dependency, HIV/AIDS and/or other conditions. These clients may not adhere to treatment regimens or use traditional medical or psychiatric services that exists for people with HIV/AIDS.
The Strathcona Mental Health Team now has two psychiatric HIV/AIDS-specialized outreach workers and there has been approval for some psychiatric sessionals to work with this program. As well, the Assertive Community Team program at GVMHS is able to provide some services to people with multiple diagnoses including HIV/AIDS.
The inter-agency Vancouver Multiple Diagnosis Committee has identified the following gaps in services that also need to be addressed:
- Supported housing options throughout the Vancouver area
- Better access to detoxification programs and facilities
- Recovery houses and treatment centres that welcome women and their children
- Grief and loss counselling
- Women’s health centres with on-site child care
- Alternative treatments and therapies
- Education of mental health professional about HIV/AIDS and its relationship to psychiatric illness, multiple diagnoses and treatment
Support for GVMHS efforts to develop educational strategies for case managers and physicians
