Michel Martin is a freelance writer living in Hull, Que.
Canadian Medical Association Journal 1995; 153: 1352-1353
[résumé]
An innovative program for patients with HIV infection or AIDS has been launched in Ottawa. It is aimed at the homeless and people with "unstable" housing who live in the city's downtown core -- a group at high risk of contracting HIV. Those at greatest risk include prostitutes, street youth and injection drug users.
The program results from collaboration among 31 social and health care agencies and the AIDS Bureau and Community Health Branch of the Ontario Ministry of Health. Among the health care agencies involved are four downtown community clinics, the Children's Hospital of Eastern Ontario and Ottawa General Hospital, and three departments within the University of Ottawa (U of O) Faculty of Medicine: epidemiology and community medicine, family medicine, and infectious diseases. The university's Health Services Unit, which provides primary care to U of O students, is also involved.
One of the 31 agencies, the Street Health Coalition, represents 25 groups that meet regularly to discuss health issues facing the homeless and those with unstable housing.
Wendy Muckle, a nurse who directs health services offered at Ottawa's Sandy Hill Community Health Centre, describes the program as "an example of how to reform health care services by making hospital services accessible and responsive to the people who use them." The program will provide services ranging from preventive to palliative care.
Muckle described the level of partnership and creativity existing among participating agencies as "innovative." In fact, planning meetings for the program were often attended by 35 or 40 people.
Dr. Gary Garber, an infectious-disease specialist at the U of O who also is director of the Immunodeficiency Clinic at the Ottawa General Hospital, described the planning process as "an invigorating experience that provided a positive link between agencies that work with the homeless and HIV/AIDS experts."
In April, the provincial government confirmed that it would contribute $603 000 to the program to supplement the $538 000 of contributions in kind that the local agencies will provide.
Danl Loewen, executive director of the AIDS Committee of Ottawa, offered this analysis of the HIV/AIDS problem as it affects the homeless: "Services don't match needs and there's a gap between street people and the providers of services. We need programs that reach out to the homeless and that provide better and integrated care."
A planning document estimates that between 3000 and 6000 people in the Ottawa-Carleton region are homeless or have unstable housing. In a recent survey of 635 injection drug users in Ottawa, 54% were considered to be homeless or to have unstable housing; between 250 and 500 HIV-positive patients in Ottawa-Carleton are considered to have the same problems.
The data are considered alarming because of the high-risk behaviour of many of the homeless and their limited access to health care services. The prevalence of mental illness and drug and alcohol abuse among the homeless make them a difficult population to reach with messages about health promotion and HIV prevention. Previously, no AIDS-related funds and limited health care funds have been provided for meeting the needs of this group.
There is also a lack of integrated care. Because treatment for substance-abuse problems and HIV infection is provided in separate programs, care for these patients is often fragmented. Other difficulties relate to accessibility of services. Existing primary-care treatment facilities are traditionally set up to suit those with stable lifestyles and have difficulty providing services to marginalized groups. One characteristic of the target population is its inability to keep scheduled appointments. As well, some treatment services have lengthy waiting periods and there is a significant danger that patients will disappear while on a waiting list.
Ottawa-Carleton has two referral centres for people with HIV/AIDS -- adults are treated at the Ottawa General Hospital's Immunodeficiency Clinic, while pediatric patients go to the Children's Hospital of Eastern Ontario. Because these facilities are located outside the downtown core, patients in the target population have difficulty making regular trips to the hospitals to pick up medication or have blood work done.
The main emphasis of the new program is to provide a continuum of services, including prevention, education, treatment and support. Program components include prevention, health care services (including primary care), nursing care and specialized medical expertise from the two hospitals. Nutrition and mental-health services will also be provided, as will help in dealing with housing problems.
The University of Ottawa will support the program through patient care, training and education of physicians and health care professionals, and research. The university's Health Services Unit will provide primary care for the program, while the Ottawa General's Immunodeficiency Clinic will offer the necessary specialized services for adults, and training and education of the program's health care personnel.
The education of family physicians will be an important priority of the program because it will expose these doctors to other disciplines, to HIV/AIDS patients, and to a marginalized clientele. According to Garber, "the future of HIV/AIDS patient care will rest with a broad base of family physicians that can provide routine management, much as what exists for illnesses such as diabetes or hypertension."
"I would have appreciated the opportunity as a student to learn how other disciplines work, and how to work as part of an interdisciplinary team," added Dr. Donald Kilby, director of the U of O's Health services Unit.
The program is currently being sponsored by the Sandy Hill Community Health Centre, and it will be located in the central area of Ottawa, close to its clientele. Organizers expect the program to be fully operational by October.