2015/16 Projects: Sexually Transmitted & Blood Borne Infections

ACTIVITIES, LESSONS LEARNED & WHAT’S NEXT

Harpa Isfeld-Kiely

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1.0 INTRODUCTION

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At the National Collaborating Centre for Infectious Diseases (NCCID), the past year has seen transition and inception of work in the context of a new host organization, the University of Manitoba, and under new leadership from co-Directors Marissa Becker and Yoav Keynan. Amid moving boxes and frequent visits by IT services, we continued active work in this area, responding to input from members of our networks who note that sexually transmitted and blood borne infections (STBBIs) still represent the largest proportion of public health workers’ caseloads and that new challenges and innovations continue to unfold, with implications for practice and policy.

In this past year, we took time to affirm and build partnerships, add value to in-person events, pilot new formats and social media platforms, take stock of new opportunities afforded by our placement at the University of Manitoba, and set the groundwork for a program science framework applied to planning. Not to be lost in deep thoughts on these plans, we also continued to respond to some clear knowledge gaps identified by public health contacts, and to do so in the timely way that is most useful to infectious disease public health. This report summarizes some of the activities from the past year—including what we heard and learned through this work—and gives a glimpse of upcoming projects.

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2.0 STBBI ACTIVITIES, 2015/16

Event

STRUCTURAL DRIVERS OF HIV – THE SOCIAL RESEARCH CENTRE SYMPOSIUM

In September 2015, NCCID participated in a symposium focused on the CIHR Social Research Centre in HIV Prevention, hosted by the Dalla Lana School of Public Health at the University of Toronto. The event celebrated achievements of the five-year program and engaged participants in discussion of a weighty question—where to from here?

The SRC has pushed the envelope toward consideration of social and structural drivers and determinants of HIV to inform public health interventions. A large volume of products and tools have issued from the program. A few examples include:

• a guide to address stigma;
• a workshop guide to support safe environments for infection disclosure to partners;
• an open access journal article on impacts of HIV criminalization on public health nurse practice;
• a website featuring documented achievements in rural HIV prevention; and
• a video that addresses stigma and promotes testing for HIV among Afro-Canadians.

You can explore SRC resources on their website or Twitter account; all products will be banked in the Sage Collection.

WHAT WE HEARD

A forward-looking discussion at the symposium identified shared concerns and gaps. Despite ample evidence in some areas, participants pointed to insufficient political engagement to support harm reduction approaches (e.g. particularly for sex trade workers and people who use drugs), decriminalize HIV non-disclosure, improve access and options for testing, develop combination prevention and multi-disciplinary team approaches, or support adequate housing and income redistributive policies that relate to infectious disease risks. The event was infused with somber recognition of the impacts of colonialism, racialization and stigma; the importance of culturally-sensitive programming; and the need for quality of life and disability supports for those now living longer with HIV, but often with significant co-morbidities.

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Event

‘REAL TIME’ KNOWLEDGE MOBILIZATION AT CATIE FORUM 2015

Many of our regional and provincial public health contacts express a familiar complaint: it is near impossible to escape one’s jurisdiction to attend some of the face-to-face knowledge exchange events on offer. With increasing fiscal constraints on public health departments, silos are only further entrenched. This challenge prompted NCCID staff to consider how we might extend the reach of in-person events–our own, or those of our partners—by harnessing new technologies and social media.

With full cooperation from CATIE, we used the CATIE Forum 2015 to test the use of an application (or ‘app’) called ‘Periscope’, developed to make production and sharing of live streaming videos quick and easy. The videos feature brief interviews with keynote speakers and the event’s lead organizer (view them here: Jordan Feld on Hepatitis C and screening; Darrel Tan on PrEP, Nitika Pant Pai on HCV POCT, Alexandra King on Indigeneity as a central component of HIV strategies, and Laurie Edmiston, Executive Director for CATIE, on event outcomes). Our primary objectives were to distill key messages and takeaways for consideration by public health, to generate some ‘buzz’ on Twitter about the event and issues, and to direct public health audiences to more information.

Pre-event audio interviews in English and French (with Roberto Ortiz Núñez of RÉZO) were used to promote the event. Tweets by NCCID (CentreInfection) and CATIE in English and French, and dubbed and captioned videos posted to YouTube broadened our cross-platform social media presence and accommodated our audiences’ language preferences. Recordings of the full keynote presentations were subsequently posted by CATIE, while the NCCID videos remain useful as a quick and convenient point of entry on issues and research dialogues that inform public health practice.

WHAT WE LEARNED

With minimal, portable equipment and a simple, streamlined process, we could quickly relay key messages tailored to public health audiences. Periscope and live streaming were only partially effective (i.e. WiFi data limitations, bugs in the app’s interface with recording hardware), but ‘Plan B’ provided for use of other social media platforms and resulted in good quality videos. The test also showed that we could efficiently produce dual language multi-media products by streamlining processes and working in close cooperation with translators. Despite an unfamiliar platform, speakers welcomed the opportunity to share their work with an expanded audience, and were highly proficient in summarizing their findings and the PH implications. The reason given for one refusal was that the speaker required communication department permission for all interviews/recordings. The event’s host noted benefits for cross-promotion and expanded reach to public health audiences. The joint-work enhanced our partnership with CATIE and seeded other ideas for collaboration.

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Webinar

NON-URBAN, YOUTH-ORIENTED HIV/HCV PREVENTION – GAHPS PARTNERSHIP

The Gender and Health Promotions Studies (GAHPS) Unit called on some local experts in sexual health promotion for youth to help address a gap in evidence-based knowledge relevant for practice in non-urban Canadian settings. Seeking commonality and lessons, GAHPS invited panelists to share examples of promising approaches to STBBI prevention in their communities during this webinar: Thinking Locally / Thinking Nationally: Looking for Synergies for Youth-Oriented HIV and HCV Prevention in Non-Urban Settings Across Canada. NCCID partnered to help engage innovators from various regions and public health audiences for consideration of the practice-based lessons. The webinar was part of a series developed by GAHPS which built on knowledge from research and consultations held in Atlantic Canada on innovative approaches to youth sexual health promotion and community readiness for HIV point-of-care testing. The webinar featured the work of three panelists:

• A presentation was given by Chris Aucoin, a gay men’s health coordinator with recent experience applying sexual social media in his work in a non-urban health region. Chris noted several advantages of social media applied in his work. In a context that has not made testing accessible, sufficiently private, or gay-friendly, social media allows him to reach men who may be marginalized from mainstream gay culture with knowledge, support, referrals, affirmation, and motivation to test. However, he describes this as a job that cannot be done within the confines of a public health worker’s standard day, as delivery needs to coincide with the timing of clients’ online activity.
• The second panelist was Candice Lys, a co-founder of FOXY, or ‘Fostering Open eXpression among Youth’, an award-winning sexual health and leadership education program for female youth in the North. The program originated in the N.W.T., but has expanded to 23 locations to reach over 1000 girls, with a parallel program for male youth in development. Candice described the program stepping into a gap, as “weak and factual” sexual health education in the Northwest Territories was irrelevant to the lives of Northern girls. The program trains peers to deliver workshops and uses a mix of contemporary and traditional arts to engage youth.
• Sara Cloutier from YouthCO joined the webinar from BC, where this initiative aims to reduce the impact of HIV and Hepatitis C on the province’s youth through peer support, education, and meaningful community engagement. As internet and cell phone service is intermittent in many communities, the program has opted to employ Facebook as well as in-person events, which remain essential to building trust and a sense of safety for the development of relationships and information exchange among non-urban youth.

WHAT WE HEARD

The panelists raised some key themes and lessons, including: the importance of applying sound principles of youth engagement and valuing youth contributions (e.g. train and pay youth peer workers); knowing the particular preferences for social media use in the community and population of interest; always working with local partners to lend credibility in reaching out to local youth; integrate mental health promotion in youth sexual health promotion.

Based at Dalhousie University, GAHPS has partnered with NCCID to develop other knowledge translation products, including scoping reviews on evaluated sexual health promotion initiatives and on evidence for the use of social media in sexual health promotion (featured in a webinar; manuscript publication pending). The reviews bring an analysis of gender, sex and sexuality to bear and focus particularly on sexual health promotion for gay men and other men who have sex with men.

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Webinar

WHAT’S THE BUZZ ON PREP?

In partnership with CATIE, NCCID led and curated two webinars for English and French-speaking public health audiences entitled: What’s the BUZZ on PrEP? Why Public Health is Listening / Quel est le buzz sur la PrEP? Pourquoi la santé publique est-elle à l’écoute? The webinars focused on the context and public health implications of gay men’s early adoption of pre-exposure prophylaxis for HIV, with varying experiences across Canada, in a quickly changing legal and social environment for this mode of prevention.

Public health practitioners sought to understand approaches taken in other jurisdictions, including who gets PrEP, what messaging, management, and support occurs in the community with regard to prevention of HIV and other STBBIs, and how public health is involved or planning policy? Moreover, public health players recognized that insight into how people at risk for HIV (particularly gay men) understand and use the medication is essential to informing implementation. The webinar program was curated by NCCID to address these information needs.

The webinars included presentations by San Patten and Marc-André LeBlanc who summarized key research findings from the ‘Resonance’ project, a community-based qualitative research study coordinated by CATIE. Drawing on impressions and understanding of PrEP among gay men and service providers in Montreal, Toronto, and Vancouver, the study served as a springboard for discussion of the implications that knowledge and social acceptability of PrEP in these communities has for public health practice.

Invited discussants (i.e. Joshua Edward, Health Initiative for Men, BC; Riyas Fadel, Ministry of Health and Social Services, Quebec; and France Janelle, Integrated Centre for Health and Social Services, Montérégie Quebec) informed the dialogue, drawing on experiences from jurisdictions with different policy environments, as well as their knowledge of guideline development, HIV prevention research, and community-based clinical settings with a role in facilitating uptake of PrEP.

WHAT WE HEARD

The level of knowledge and the discourse on PrEP varies widely, with some gay men and service providers being highly informed and others knowing little (although this may be changing, particularly since Health Canada approved Truvada for use as PrEP in February 2016). Contexts and supports for PrEP uptake also vary widely by region and urban/non-urban location. For example, there is relative ease of access to PrEP in Quebec, where practitioners advertise its availability and mainstream media reports are common. However, barriers to access remain in Vancouver, despite high client demand and interest from service providers. Few private insurance plans cover Truvada for use as PrEP. Generic importation and travel to the US are some known means of access, as was described for Vancouver and surrounding areas. As well, some gay men are known to access Truvada from those treated for HIV. This creates circumstances where no health care providers are involved in counselling or follow-up. This sparks concern for coinfections, particularly in a context of syphilis or gonorrhea outbreaks, as well as for the need to monitor potential side-effects of Truvada.

Gay men are understood to be relying on word of mouth, grassroots media, and some community-based gay and bi men’s health agencies (like HIM and REZO) for information on PrEP. Otherwise, there is little sense of where they receive quality information, and those at the margins of gay men’s networks or those who do not identify as gay/bi men may not be connected to these supports. Agencies like HIM are also working to counter stigma associated with Truvada that deters use by those who could benefit from PrEP. The agency counsels men to support self-efficacy and self-advocacy skills for men to adopt PrEP as a safer sex method.

While some public health discourse focuses on condom use versus PrEP, discussants emphasized the importance of taking an approach that provides options that best fit client circumstances and comfort. ‘Resonance’ findings and this discussion suggested there is a need for a public health stance on PrEP and for public health messaging. This might begin by clearly addressing questions of who can benefit from PrEP, where can PrEP and associated follow-up be obtained, and how can it be obtained, or with what resources and added supports. We learned that public health, together with partners in community, needs to build capacity to counsel gay men, as well as others who may benefit from PrEP, including serodiscordant couples planning a pregnancy and women seeking greater personal control over HIV protection.

As results of many demonstration studies on PrEP accrue and with draft national guidelines having been recently released at CAHR, conversations on how best to implement PrEP and achieve consistency in management clearly must continue. Public health professionals are encouraged to continue to dialogue on considerations for their practice in this rapidly changing HIV prevention environment.

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Network

STBBI NETWORK SUPPORT

Beginning in 2014, NCCID has supported a national network of urban public health professionals working in the area of STBBI prevention and control—the Urban Public Health STBBI Network. Primarily, the group’s activities centre on quarterly teleconferences for the purposes of direct information sharing, drawing on diverse expertise from program directors or managers in CDC units, healthy sexuality and harm reduction programs, epidemiologists, and public health nurses at front-lines of service delivery. Associate members include NCCID, CATIE and PHAC, who participate as knowledge brokers, mobilizing new knowledge products, and gaining timely information on emerging issues and knowledge gaps. Given the limited forums available to public health practitioners for collaboration, the network is highly valued by members, receiving positive evaluations and active participation, particularly from mid-sized urban public health units.

WHAT WE HEARD

Rich exchanges among this network have shown many areas of shared interest and key knowledge gaps. A few themes with relevance for broader audiences should be highlighted. First, infectious syphilis remains a significant challenge, with nearly all urban centres reporting outbreaks, and some reporting spread beyond urban centres (e.g. Thompson, Manitoba). Gay or bi men represent a clear majority of cases, although increases in heterosexual and female cases have been noted in some populations (e.g. in Winnipeg, Edmonton, Ottawa). NCCID is currently assessing needs and potential focal points for further knowledge exchange on effective strategies for prevention and control of syphilis (see below). Secondly, network members identified a need to better understand gay/bi men’s knowledge and uptake of PrEP, as well as their experiences with prescribers, to consider implications for public health (subsequently addressed by NCCID-CATIE webinar, see above). Thirdly, participants share interest in standards for public health messages to HIV clients about non-disclosure of their status, with concern that information be more consistent with evidence as well as messages from other service providers. Finally, urban public health departments increasingly face challenges meeting escalating needs for safe drug injection with limited resources for harm reduction services, with implications for the HIV and hepatitis C epidemics.

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3.0 UPCOMING ACTIVITIES & PRODUCTS

Syphilis knowledge exchange event, 2016/17

In 2014, a common theme emerged from an evaluation of NCCID’s ‘Forward Thinking on Syphilis’ event: sustained, national, coordinated action is needed to make headway on syphilis. At that time, public health professionals, working at all levels and in varied roles, called for a follow-up event. Motivation for continued work comes from epidemiological evidence of protracted outbreaks in several centres, primarily affecting MSM, with increasing numbers of female and heterosexual cases and accompanying concerns for risk of congenital syphilis. Several specific suggestions on potential priorities for a future meeting were offered in the evaluations and in dialogue with the STBBI Network (see text box). In addition to this input, an expedited scan of current issues is underway. An invitational event is anticipated for late fall of 2016.

Syphilis knowledge gaps and priorities

Participants in the 2014 ‘Forward Thinking on Syphilis’ knowledge exchange event and members of the Urban Public Health STBBI Network have expressed strong interest in further collaboration to plan effective strategies for the prevention and control of syphilis. The following themes on knowledge gaps and future priorities emerged from responses to an evaluation of the 2014 event (n=28), a ‘virtual roundtable’ questionnaire (n=7) that asked “What more is needed to make an impact on the burden of syphilis?”, and from dialogue with Network participants. Paraphrased responses are summarized by theme, below:

Interests ranged widely according to public health functions:

• How to strengthen and clarify surveillance
• Syphilis screening strategies–integrated, routine, what is optimal and cost-effective?
• Share effective strategies for outreach

Some suggestions focused on strategic, cross-disciplinary / cross-sector collaboration:

• Linkages and awareness building with primary care, e.g. involve College of Physicians and Surgeons
• Mobilizing community partners for health promotion, e.g. practice-based lessons from partnership with the sex trade industry

Others reflected concerns for spread to new, vulnerable populations:

• Address knowledge gap in rural public health, as syphilis has spread beyond urban centres (e.g. Manitoba)
• Strategize on supports protective of vulnerable women in inner city communities, including Indigenous women (also as partners)

Use of particular methods, innovative tools, integrative or systems approaches characterized the remaining suggestions:

• Potential of mathematical modelling to support decision-making on syphilis
• Share effective use of social media—innovations in testing technology and programs (e.g. rapid and anonymous testing)
• Develop a program science agenda—a more coordinated national approach is called for
• Feature combination prevention—combining biomedical, behavioural and structural interventions
• Frame out a ‘cascade of care’ for syphilis? How can we establish clear and shared goals and track progress?

HIV Cascade of Care Indicators

There is growing attention brought to bear on how well we are engaging people living with HIV in a continuum of services including testing, care, and effective treatment. ‘HIV Cascade’ is the concept that has emerged as a way to track progress at points along this continuum and identify the gaps in services that prevent people from fully benefitting from antiretroviral therapy. Toward this end, PHAC is developing national measures for a six-element HIV cascade (i.e. people living with HIV, diagnosed, linked to care, retained in care, on treatment, viral suppressed). NCCID will support this process by hosting a knowledge exchange forum early in 2017. The purpose of the forum is to invite a wider audience—including HIV surveillance partners, stakeholders and public health specialists—to provide feedback on work undertaken by the National HIV Cascade Working Group which aligns national HIV cascade indicators definitions. The forum will also present an opportunity to discuss the interpretation of the cascade, the implications for public health decisions and the implementation process across the different jurisdictions. NCCID’s contributions will include the development of a plain language case study reporting on the success and challenges of British Columbia and Manitoba HIV programs in measuring these indicators and a technical report on the consultation process.

Partner Notification Guidelines

NCCID was recently invited by PHAC to contribute to summary guidelines for partner notification specific to reportable STBBIs (syphilis, gonorrhea, chlamydia, and HIV) as a means to address a recognized gap in existing guidelines and the need to work toward a common approach. The initiative will include the use of internet and expedited partner notification and address concerns of efficiency and trace-back time—areas of growing interest. The work will build on earlier reviews of evidence and stakeholder consultations led by NCCID.

Indigenous Youth Sexual Health (NCCAH Partnership)

In the coming year, the National Collaborating Centre for Aboriginal Health (NCCAH) embarks on a new project focused on Indigenous youth sexual health, with NCCID as a partner. Lessons from Indigenous research and communities will be of interest to public health professionals increasingly seeking fresh insight on strategies for infectious disease prevention and control through partnerships with Indigenous peoples and deference to Indigenous knowledge.

Modelling Applications for Syphilis Screening Strategies

Increasingly, public health decision-makers look to disease modelling to evaluate the effects of intervention strategies, but capacity and comfort with modelling research and its interpretation is lacking. In partnership with public health analysts and modellers, NCCID will develop a ‘case study’ that exemplifies promising practices for collaboration between public health and mathematical modellers. This will include examples of the kinds of questions public health should ask of modellers to help ensure more realistic models are developed with clear implications for policy or practice. Strategies for targeted syphilis screening will serve as the subject for the case study.

Focus on Testing – Manitoba HIV Collective Impact Network

NCCID is participating in some collaborative initiatives focusing on testing for STBBIs. One example is the ‘Manitoba HIV Collective Impact Research-Evaluation-Action Network’, launched in March 2016 and hosted by Nine Circles Community Health Centre, with funding from REACH. This Manitoba-based network brings together researchers, community-based organizations, health authorities, policy-makers, Aboriginal and Northern Health leaders, peers and others to work on common HIV goals. The Network is distinct in its application of a particular systems approach called ‘the collective impact approach’ (See tamarackcommunity.ca) which aligns and leverages existing expertise and programs to greater effect. The overarching goal of the network is to double HIV testing in at-risk groups by 2019 by assessing and increasing community and individual readiness and ultimately impacting health outcomes, client and provider experience, and health system outcomes in Manitoba. (Twitter: @MBHIVCollectiveImpact. For more information and updates on progress, contact: Laurie Ringaert at LRingaert@ninecircles.ca).

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4.0 IN SUM & LOOKING AHEAD

In a year of transition, NCCID remained active in mobilizing knowledge for the prevention and control of STBBIs. The Centre built on previous work, explored new methods, and developed complementary partnerships while responding to identified knowledge gaps. Our networks, collaborators and partners in public health can expect our continued role facilitating collaborative dialogue, curated for public health interests and evidence-based decision-making.

We welcome your input on defining emerging issues in this area. Please send your comments or inquires to: nccid@umanitoba.ca

NCCID Project No. 273