The Road for Wellness with HIV Services

Peer Delivered Services Needs Assessment

in the B.C. Interior Health Authority Region

Project Facilitator: Kira Haug (Health Navigation/Education, ASK Wellness Society)

Project Steering Committee: Cheryl Dowden (Executive Director, ANKORS), Lorena Hiscoe

(Operations Manager - Communicable Disease, Interior Health), Bob Hughes (Executive

Director, ASK Wellness Society), Clare MacDonald (Executive Director, Living Positive

Resource Centre)

Editorial Assistance: John-Paul Baker

Prepared for the B.C. Interior Health Authority

March, 2014

EXECUTIVE SUMMARY

In 2012, the British Columbia Ministry of Health released “From Hope to Health: Towards and AIDS-

free Generation”, which laid out strategies for B.C.’s health authorities in further implementing the

Treatment as Prevention approach. This document recommended several methods of engaging and

retaining people in HIV care and treatment, including effective delivery of Peer Delivered Services

(PDS).

Following from the recommendations of the Ministry of Health, this inquiry examined the current state of

PDS for those newly diagnosed with HIV within British Columbia’s Interior Health Authority (IHA).

Through research as well as surveys, key informant interviews, and working group interviews with 25

peer-clients and 22 frontline service providers, data was collected regarding:

services currently available within the IHA

the experiences and opinions of peers involved in PDS

the social determinants of health for people living with HIV

strategies for core leadership development in the implementation of PDS

components of success for PDS

challenges and barriers to effective implementation of PDS

This inquiry on Peer Delivered Services supports several key recommendations for the Interior Health

Authority:

1. Funding should be given to AIDS Service Organizations (ASOs) and other agencies that provide

HIV support services in the Interior Health Authority region to provide support to peers living with HIV.

2. Agencies should make concerted attempts to provide people living with HIV with opportunities

to engage in core leadership development and services.

3. Funding should be provided to train people living with HIV who demonstrate an interest in

developing core leadership.

4. Strategies should be developed to support HIV-positive individuals living in remote communities

through telecommunications and the Internet.

5. Multiple PDS approaches should be explored, since a singular approach may not be suitable for

all communities within the IHA.

6. A region-wide Peer Advisory Committee should be developed to make future recommendations

on PDS within the IHA.

Following these recommendations, it is hoped that the Interior Health Authority may continue to enhance

supports to people living with HIV and improve their overall well-being.

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TABLE OF CONTENTS

1. BACKGROUND .................................................................................................................................. 2

1.1 Introduction ................................................................................................................................... 2

1.2 Purpose .......................................................................................................................................... 2

1.3 Responses to HIV in British Columbia ......................................................................................... 3

1.4 Existing Services ........................................................................................................................... 4

Agencies serving people living with HIV/AIDS .................................................................................. 4

Types of peer delivered services offered in the Interior Health Authority Region ............................... 6

2. METHODOLOGY ............................................................................................................................... 7

2.1 Inquiry Approach .......................................................................................................................... 7

2.2 Data Collection ............................................................................................................................. 7

2.3 Ethical Considerations .................................................................................................................. 9

3. FINDINGS ............................................................................................................................................ 9

3.1 Results ........................................................................................................................................... 9

3.1.1 Peer-Client Results ................................................................................................................ 9

3.1.2 Front Line Service Provider Results ................................................................................... 14

3.2 Study Implications ...................................................................................................................... 18

3.2.1 Implications for Peer Mentors and the Newly Diagnosed .................................................. 18

3.2.2 Implications for IHA and Organizations Providing Services .............................................. 19

3.3 Study Limitations ........................................................................................................................ 19

4. RECOMMENDATIONS .................................................................................................................... 20

4.1 Study Recommendations............................................................................................................. 20

4.2 Organizational Implications ........................................................................................................ 21

4.3 Recommendations for Future Inquiry ......................................................................................... 21

APPENDIX A - British Columbia Interior Health Authority ..................................................................... 22

APPENDIX B - Peer-Client Survey Tool ................................................................................................... 23

APPENDIX C - Front Line Service Provider Survey Tool ........................................................................ 27

APPENDIX D - Confidentiality/Consent Form .......................................................................................... 30

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1. BACKGROUND

1.1 Introduction

This inquiry has its roots in the British Columbia Ministry of Health’s STOP HIV/AIDS campaign, an

implementation of the Treatment as Prevention approach in British Columbia. Three years into the

campaign, the Ministry of Health released “From Hope to Health: Towards and AIDS-free Generation”,

which laid out strategies for BC’s health authorities in further implementing the Treatment as Prevention

approach. This document recommended several methods of engaging and retaining people in HIV care

and treatment. Among these recommendations was:

“Implement or enhance peer services to assist those newly diagnosed with HIV infection to seamlessly

connect them to care and treatment services.”(“From Hope to Health: Towards an AIDS-free

Generation”, BC Ministry of Health, 2012)

Following from this recommendation, this inquiry examines the current state of Peer Delivered Services

(PDS) for those newly diagnosed with HIV infection within British Columbia’s Interior Health Authority

region. The aim is to make recommendations to the Interior Health Authority (IHA – see Appendix A for

a map of the region) regarding the effectiveness of peer driven service models in both urban and rural

contexts in order to connect the newly diagnosed to the appropriate care and treatment services. This

inquiry aims to identify programs and services that currently provide HIV support and to enhance

understanding of the needs of community members living with HIV. This inquiry also explores the

experiences of agencies delivering front-line services, in the hopes of furthering our understanding of

effective peer driven service delivery.

The work of this inquiry was guided by a Project Steering Committee, comprised of the following

individuals:

Cheryl Dowden – Executive Director, ANKORS

Lorena Hiscoe – Operations Manager - Communicable Disease, Interior Health

Bob Hughes – Executive Director, ASK Wellness Society

Clare MacDonald – Executive Director, Living Positive Resource Centre

1.2 Purpose

The British Columbia Ministry of Health requested that each provincial health authority determine the

involvement and contribution of HIV Positive individuals (Peers) in regards to programming and service.

Additionally, there was an expectation that AIDS Service Organizations (ASO’s) and agencies that

provide HIV services deliver support to the newly diagnosed, reduce transmission of the virus, promote

early diagnosis, and encourage treatment and long-term support to those living with HIV. To these ends,

several questions emerged in the early stages of this inquiry:

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What have been the experiences for the long term diagnosed (elders), newly diagnosed, and

agencies that provide services in regards to Peer Delivered Services?

Can Peer Delivered Services be delivered region wide? Is this desired? What are the challenges

in how we support urban and rural communities?

These questions have driven this inquiry at every stage and led directly to the following project outcomes:

1. Identification of current models of Peer Delivered Service for those newly diagnosed with HIV

infection.

2. Identification of programs which are adaptable to both urban and rural setting and can be

delivered remotely.

3. Recommendations for development of Peer Delivered Service within the Interior Health

Authority. Recommendations must consider the need for PDS to be delivered throughout all areas of

the IHA under existing Blood-Borne Illness contracts, making effective and efficient use of

resources.

1.3 Responses to HIV in British Columbia

The incidence of new transmissions and diagnosis of HIV has decreased in British Columbia. In fact, the

2011 Communicable Disease Annual Report announced that B.C. is the only province that has

demonstrated a “steady decline” in newly reported HIV and acquired immune deficiency syndrome

(AIDS). Such success has allowed B.C. Health Minister Margaret MacDiarmid to declare that “British

Columbia is at the forefront in the fight against HIV and AIDS.”

Key to the decrease in HIV transmission are the multiple partnerships between the B.C. Ministry of

Health, St Paul’s Hospital in Vancouver, the individual health authorities, and the service agencies

dedicated to improving the quality of life for people living with HIV. Together, these partners have

contributed to the “successes of sustained HIV prevention in B.C.”. (BC Centre for Disease Control 2013.

HIV in British Columbia: Annual Surveillance Report 2012.)

Several interrelated initiatives and strategies over the past five years are particularly noteworthy. These

include:

Treatment as Prevention (TasP) Approach

Treatment as Prevention is an intervention tool designed by Dr. Julio Montaner and his team at the B.C.

Centre for Excellence in HIV/AIDS (BC-CfE). The concept is to treat those who are eligible so that the

condition is manageable and the chance of transmitting the virus further is decreased. Prevention thus

comes as a result of treatment.

Seek and Treat for Optimal Prevention of HIV/AIDS (STOP HIV/AIDS)

The Seek and Treat pilot program of the STOP HIV/AIDS Program was conceived at the B.C. Centre for

Excellence in HIV/AIDS as a real-world implementation of the TasP Approach. Seek and Treat expanded

access to HIV/AIDS medications among hard-to-reach and vulnerable populations in Vancouver’s

Downtown Eastside and Prince George.

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It’s Different Now Campaign - STOP HIV

The It’s Different Now Campaign aimed to raise awareness about HIV and HIV testing and encourage

people to consent to be tested when an HIV test is offered. To reduce stigma around HIV and HIV testing,

It’s Different Now launched a social marketing campaign developed by the Vancouver STOP Project

designed to change how the public perceives HIV and HIV testing.

From Hope to Health: Towards an AIDS-free Generation - British Columbia Ministry of Health

Following the successes of the STOP HIV/AIDS pilot project, “From Hope to Health” laid out several

strategic goals for the provincial health authorities:

1. Reduce the number of new HIV Infections in British Columbia.

2. Improve the quality, effectiveness, and reach of HIV preventions services.

3. Diagnose those living with HIV as early as possible in the course of their infection.

4. Improve quality and reach of HIV support services for those living with and vulnerable to HIV.

5. Reduce the burden of advanced HIV infection on the health system.

The initiatives and strategic frameworks above have assisted frontline agencies in delivering services to

people living with HIV in the Interior Health Authority region.

1.4 Existing Services

Agencies serving people living with HIV

Following is an overview of some of the agencies that provide support programming and services to

people who are living with HIV in the Interior Health Region. Many of these agencies are linked to case

management care and provide specialist services. This list does not include all services available to date

but highlights those which emerged through this inquiry.

Oak Tree

Oak Tree provides specialized clinical care for women and children living with HIV/AIDS. The

interdisciplinary clinical team includes physicians (Adult, Pediatric, and Obstetric/Gynecological),

dieticians, outreach workers, nurses, pharmacists, and social workers. Oak Tree educates patients and

their families, other health care workers, organizations and institutions, and the public about the complex

issues of HIV infection in women and children. Oak Tree advocates for improved prevention, diagnosis,

care, and support; Oak Tree also contributes to clinically oriented research and improving access to

clinical trials and other research for women and children. (www.oaktreeclinic.bc.ca)

St Paul’s Hospital: The BC Centre for Excellence in HIV/AIDS (BC-CfE)

Recognized as a world leader in fighting Blood Borne Infections , BC-CfE (St Paul’s) is Canada’s largest

institution in HIV/AIDS research, treatment, and education. Since 1986, St Paul’s has administered Anti-

Retroviral (ARV) therapy to treat HIV/AIDS in thousands of people. They provide hospital and

residential services, outpatient programs, and services. St Paul’s provides care, treatment services,

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education to over 65% of the seropositive people in the province. Also based at St. Paul’s Hospital is the

Canadian HIV Trials Network (CTN), a partnership of clinical investigators, physicians, nurses, and

individuals who are living positive that facilitate clinical trials for research. St Paul’s and Positive Living

BC (PLBC), a Vancouver based ASO, partner to provide Peer Navigators to assist newly diagnosed

people to access treatment, education, and support. (www.providencehealthcare.org)

Positive Living BC

Positive Living BC (PLBC) provides an environment where individuals who are living positive with HIV

can access mutual support. PLBC is the largest HIV organization in Western Canada, comprised of over

5,400 positive members and a Board made up of Directors who themselves are living positive. The

organization provides access and assistance, health education, peer navigation, prison outreach, a positive

action committee, group support, workshops, retreats, physician registry, in-house services, resource

creation, and a full color magazine. (www.positivelivingbc.org)

Positive Women’s Network

Positive Women’s Network (PWN) provides education, support, and resources for women living with

HIV in British Columbia and for service providers in health and social services across the country. For

women with HIV, they offer support and advocacy as well as HIV education, health promotion resources,

and community connections. (www.pwn.bc.ca)

The Red Road HIV/AIDS Network

The Red Road HIV/AIDS Network is a B.C.-based Aboriginal Organization with over 125 members from

Aboriginal AIDS Service Organizations (ASO), non-aboriginal ASOs with Aboriginal programming,

Aboriginal Persons living with HIV, and Aboriginal organizations which have HIV programs located in

urban and rural settings. Services include support programs in education, treatment and care, peer

counselling, advocacy, and workshops on HIV/AIDS and Hepatitis C. Red Road also provides training

for members, frontline workers, facilitators, caregivers, health care workers and educators four times per

year. Resource materials include the Bloodlines magazine. (www.red-road.org)

The Pacific AIDS Network

The Pacific AIDS Network (PAN) works in partnership with 57 service agency members province-wide

to facilitate communication, education, and supports to respond to HIV/AIDS and to promote best

practices in the care of HIV-positive individuals. PAN provides face-to-face networking opportunities,

opportunities for mutual support, education, and skills development, and promotes community-based

research. PAN also provides education and training for positive individuals to realize and harness their

leadership potential though the Positive Leadership Development Institute (PLDI). This core leadership

training provides the skill development for individuals to become a part of peer delivered service

opportunities. (www.pacificaidsnetwork.org)

ANKORS

East Kootenay and West Kootenay/Boundary area (AIDS Network Outreach & Support Society)

ANKORS has been providing services since 1992. ANKORS provides support to persons living with HIV

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and those at risk. ANKORS networks with health care, service providers, and community members to

improve access to support, outreach, and care services in our region. (www.ankors.bc.ca)

AIDS Vancouver

AIDS Vancouver opened its doors in 1983 as the first AIDS service organization in Canada in response to

the growing need for community health organizations to support individuals vulnerable to the epidemic.

Today, over 7,000 people from all over the world are annually accessing some form of service provided

by AIDS Vancouver. AIDS Vancouver continues to respond to the ongoing changing and challenging

health care environment of HIV/AIDS and is fully dedicated to growing and responding to meet the needs

of the community. AIDS Vancouver strives to keep programming innovative and relevant for people

affected by HIV/AIDS who experience difficulties in accessing services or have a financial,

transportation, medical, food, housing, or other problem or emergency. Services available from AIDS

Vancouver include: Case Management Services, Financial Assistance Fund, Grocery and Nutrition

Support, Outreach Care Teams Support and Confidential Helpline Support. (www.aidsvancouver.org)

North Okanagan Youth and Family Services Society

North Okanagan Youth and Family Services (NOYFSS) has been serving families of the North Okanagan

since 1974. NOYFSS provides counselling and support services to individuals and families through a

variety of community-based and residential programs. NOYFSS is committed to removing barriers for

individuals with (but not limited to) physical/mental/developmental exceptionalities, sensory problems

(visual, auditory, etc.), poverty, and language/cultural needs. (www.noyfss.org)

Living Positive Resource Centre, Okanagan

Living Positive Resource Centre has operated out of Kelowna since 1992. The agency provides support

and advocacy services to the Okanagan region. The agency currently serves anyone with issues related to

housing, income, nutrition, access to health care services, addictions, and mental health. They provide

prevention, education, and support services to anyone living with, affected by, or at risk of HIV, Hepatitis

C, and other conditions. (www.lprc.ca)

ASK Wellness Society

ASK Wellness Society has been providing outreach, housing, and programming to Kamloops, Merritt and

surrounding communities for the past 20 years. They provide a vast array of services dedicated to

supporting people who are marginalized to improve the quality of their lives through the Streets-Health-

Home-Employment initiative. Programming provides situational education to people who are homeless,

people who use drugs, and/or those suffering from a mental illness. Client-centered care focuses on harm

reduction strategies that reduce the infection rates of blood borne pathogens, enhances the health of

persons served, and increases the safety of the community. (www.askwellness.ca)

Types of peer delivered services offered in the Interior Health Authority Region

There are a several examples of Peer Delivered Services being operated in the Interior Health Authority.

These include:

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Support Groups

Some agencies have or have had peer-led support groups for individuals living with HIV.

Health Navigation

Some formalized BBI Health Navigation Services currently operate in the region.

Harm Reduction (HR) Distribution

There are some informal and formal HR services currently being offered in the region. Informal services

typically consist of peers that either carry extra HR on them to distribute to peers or refer people to testing

sites.

Peer-to-Peer Supports

Some informal peer-to-peer relationships have been established. These are largely mutually supportive

relationships based on friendship.

Peer Board Members

Some agencies have formally included peers by asking them to sit on the Board of Directors for their

ASO and have supported those living with HIV and involved in their agencies to participate in Peer

Leadership Training opportunities provided by organizations such as the Pacific AIDS Network.

2. METHODOLOGY

2.1 Inquiry Approach

A survey method of inquiry was used as a means to include as many people as possible involved in HIV

services and individuals who are HIV positive within the region. Two surveys were created: one for Peer-

Clients (see Appendix B) and another for front-line staff providing services to people living with HIV

(see Appendix C). The Project Steering Committee and Project Facilitator met frequently to discuss the

language of the surveys, the desired audience, and the overall direction of the survey.

Complementing the survey were one-on-one key informant interviews and working group interviews with

groups of five to twelve participants. One-on-one interviews allowed for better privacy for those who

preferred it while working group interviews allowed for broader participation and worked well for larger

communities (Kamloops and Nelson).

2.2 Data Collection

Both the front-line staff survey and the peer-client survey focused on experiences with, benefits of, and

challenges to Peer Delivered Services. Survey questions sought to explore the following issues:

What were the benefits and challenges of delivering, receiving, and implementing PDS?

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What experiences did people have in delivering and participating in PDS programs and what do

peers want in regards to additional services?

Did respondents consider themselves to reside in an urban or rural community?

What programs or services were peers and clients engaged in and what kinds of barriers existed

in obtaining services to meet their needs?

The surveys also included an invitation to participate in an in-person meeting. For complete surveys,

please see Appendices B and C.

The first step in data collection was to send both surveys to the Blood Borne Infections Partnership

Network via email and to make the surveys available at the ASK Wellness website. Email to participants

directed them to the surveys at ASK’s website via an embedded link. Once these surveys were returned, it

was possible to identify service agencies that were interested in participating in the project. Agencies

were asked whether they wished to have the Project Facilitator visit and conduct key informant interviews

or a working group interview.

Contact was also made with Kim Louie (Executive Director of Red Road) and Jennifer Evans Jones

(Executive Director of the Pacific AIDS Network) to inquire how to engage members of their province-

wide organizations living within the Interior Health Authority. By contacting PAN, the Project Facilitator

was able to access the Positive Leadership Development Institute (PLDI) and invite their program

participants that live in the IHA region to contribute to this project. Laurie Edminston (Executive

Director of CATIE) was asked to provide information regarding Peer Delivered Service and CATIE’s

experience thus far as one of Canada’s National Partners in the response to HIV.

A total of 25 peers responded to the peer-client survey; three of these respondents completed the survey

on-line, while the remaining 22 – due to limited computer literacy or access - were assisted by agency

staff or the Project Facilitator in completing the survey. Agency personnel from 22 service providers

completed the Front Line Service Provider Survey.

Key informant interviews and working group interviews were conducted throughout the region, including

eight one-on-one key informant interviews (in Kamloops, Merritt, Williams Lake, Kelowna, and

Cranbrook) as well as two working group interviews, with twelve and five participants in Kamloops and

Nelson, respectively.

To support the work of this project, the Project Facilitator also visited the following agencies and

individuals over the course of a two-week project tour: ANKORS (East and West), Living Positive

Resource Centre (Okanagan), ASK Wellness Society, Boys and Girls Club Williams Lake, Street Angels,

Salvation Army (Cranbrook) Thompson Rivers University Williams Lake campus Nurse Practitioner,

STOP HIV Nurse Outreach Team (Cranbrook, Kamloops and Nelson), North Okanagan Youth and

Family Services Society, and the Cammy Lafleur Street Outreach Program.

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2.3 Ethical Considerations

In completing this project, several ethical considerations were taken into account:

Confidentiality/Consent

A joint Confidentiality/Consent Form was signed by both the participant and the Project Facilitator. The

joint form stated that participants’ names would not be used in the preparation of the document and the

sharing of information. (see Appendix D for full Confidentiality/Consent Form)

Audio Recording

At the beginning of each one-on-one interview or working group interview, the Project Facilitator sought

permission to record the discussion. A participant could decline without issue and change his/her mind

after having given permission previously to the session recording. This information was included on the

Confidentiality/Consent Form.

Incentives to Participate

A meal (lunch) and $20 cash honorarium were offered in recognition of the importance and value of

participants’ experiences.

Financial Integrity

In giving a cash honorarium to participants, a Sign-in/Acceptance sheet was created to keep count of

individuals attending and the cash provided. Participants were asked to provide three initials (thereby

preserving a degree of anonymity) in exchange for the cash honorarium.

3. FINDINGS

3.1 Results

3.1.1 Peer-Client Results

Of the 25 participants who completed the survey, 21 identified as peers, three as peer service providers,

and one as a stakeholder. Peer-client survey participants came from a variety of communities, including

Kamloops, Kelowna, Penticton, Nelson, Cranbrook, Vernon, Kimberley, Robson, and Merritt. When

asked whether they lived in a rural community, 34.8% of 23 participants who responded to the question

answered “yes”, while 65.2% answered “no”.

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Participants shared a broad range of ideas regarding PDS which can be grouped into three major themes:

experience and opinions, social determinants of health, and core leadership development.

Experience and Opinions

Eight respondents indicated they had not had any experience with PDS, seven said they were uninterested

in PDS, and eight indicated they had previous experience with PDS. Of those eight with PDS experience,

five indicated PDS experience in Vancouver, three at ASK Wellness in Kamloops, and two at ANKORS

in Nelson (note that a participant may have had experience with more than one PDS in more than one

location).

When asked whether receiving support services from a peer support worker would be more desirable than

from a non-peer, 39.1% preferred a peer, 69.6% were comfortable with a peer or non-peer delivering

professional services, 4.3% did not know, and 17.4% chose other.

35%

65%

Peer-Client Survey Respondent Location

Rural

Non-rural

30%

54%

3%

13%

Desired Support

Prefer a peer

Comfortable with eitherpeer or non-peer

Don't know

Other

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Peer-client survey respondents noted several key benefits of PDS, including:

increased empathy and sensitivity to the plight of someone newly diagnosed with HIV or for

someone living with HIV

swifter access to appropriate and helpful services, including: depression and grief and loss

counselling, ARV Therapy and specialist support, a nutritionist, support groups or peer support,

advocacy for additional benefits (PWD and nutritional allowance), and HIV education that was

easy to understand

preparation and information on how therapy might make a newly diagnosed person feel

comfort that “I am not alone” in this

Respondents also drew attention to several key barriers to the effective delivery of PDS, including:

confidentiality, which emerged as the number-one concern of every participant; particularly in

rural communities, discussing one’s HIV-positive status is perceived as risky and accompanied

by a strong fear of stigma and discrimination

discrimination within the sub-populations of the HIV community; the differences among

individuals regarding how they contracted HIV (sexual vs. IDU), was identified as a major barrier

to deliver or receive PDS; other salient differences include: age, gender, socio-economic status,

cultural background, and sexual orientation

the risk for people who have a history of substance abuse, who may encounter triggers when

delivering PDS

power differentials, which are of particular concern among the gay/MSM population; specific

concerns were raised about the following issues in regards to power differentials:

a. There was a perception that elder peer mentors may have difficulty with boundaries

concerning younger males newly diagnosed. While this barrier may or may not exist, the

perception itself presents a barrier to service.

b. Paid peers create an imbalance of power; agency favoritism may become an issue.

c. PDS may contribute to a two-tiered hierarchy within the HIV community: those who

are acknowledged and paid and those who are not

d. Someone would have to make appropriate matches between peer mentors and peers.

One example given was that an Elder Peer who identified as being gay would lack the

relevant life experience to properly support a newly diagnosed 24-year-old First Nations

woman.

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Social Determinants of Health

Of 25 respondents, 11 had been positive for ten or more years, six for ten or fewer years, six for five or

fewer years, and two had been diagnosed in the past year.

Participants were asked what agencies and services they accessed regularly. All but two utilized one or

more of the following: an ASO or service provider, food bank, mental health services, outreach, YMCA,

Interior Indian Friendship Centre, chemical dependency program, a church program, meals program,

street nurse, or STOP nurse. The food bank and an ASO were the two most common responses.

Services that were unavailable to rural communities and would help with the quality of life of people who

are positive include: housing, drop-in centres, nutrition consulting, improvements in current food bank

services, doctors, clinic and specialist access, education, and transportation.

62.5% of the participants indicated they currently engage in some kind of health navigation programming,

20.8% attend support groups, 33.3% access harm reduction services, 54.2% use outreach services, and

37.5% indicated they participate in other programming such as recovery supportive housing, methadone

clinic, detox, and education.

Several underlying subthemes emerged within the theme of social determinants of health:

1. Poverty

Poverty was a leading commonality among all those that were interviewed. Paying rent and affording

medication, food, and other basic living expenses were identified as significant challenges.

2. Housing

Housing is serious concern throughout the IHA region. Housing subsidized by B.C. Housing has long

wait lists, there is a lack of affordable market housing options, and many individuals live in Single Room

Occupancy (SRO) housing. Several participants mentioned a desire for long-term supportive housing

specifically for persons who are living with HIV.

44%

24%

24%

8%

Time since diagnosis

10 or more years

6 to 10 years

1 to 5 years

Less than one year

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3. Nutrition

Access to good food and balancing one or more chronic health care conditions is difficult. A majority of

respondents rely on the Food Bank, which makes it challenging to maintain a high-protein diet. The

nutritional allowance is not enough to support healthy nutrition since protein and produce are very

expensive.

4. Availability of Health Services

Inequity of services and a lack of access to physicians, clinics, specialists, and care providers emerged

frequently in interviews and surveys.

Services that are delivered by Internet or email were reported as inadequately accessible. Phone support

might be a better fit as most people have consistent access to a cell phone or landline.

Mental health issues as a result of grief and loss, depression, isolation, community discrimination, and

medical discrimination (treatment at a hospital, emergency room, or doctor’s office) were identified as

barriers. Stigma and discrimination are particularly acute in small rural communities.

5. Transportation

Lack of transportation can be an obstacle to getting even one chore done per day in many communities.

Participants in rural communities described having to hitchhike to and from labs in order to complete

required bloodwork, or, in some cases, trying to find somewhere to stay for the night to have to travel

back the next day. Beneficial services are often not accessed due to transportation barriers, inclement

weather, lack of resources, and time limitations. In urban centres, clients had greater access to services

but still described walking almost everywhere or needing a bus pass. Travel to see a specialist was a

concern for many; however, those in urban centres had some access to health navigators/family/peer

escorts or accessible Greyhound service. In rural areas such as Nelson and Cranbrook, travelling to

Vancouver was described as a massive undertaking involving up to 10 hours of travel each way plus

costly hotel and meals.

Core Leadership Development

76.2% of the group responded that they would be interested in learning more about opportunities to

training and supports around Peer Leadership Development (PLDI –PAN), with 23.8% indicating they

were not interested in these opportunities.

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In discussions of core leadership and participation as peer mentors in the delivery of PDS, respondents

raised several issues:

1. Computer literacy: Computer literacy and access (which would enable remote support)

emerged as more of a barrier than an asset to communication for those rurally located. The costs

associated with owning a computer and paying for Internet service are prohibitive, agencies with

computer access are usually open only 8:30 to 4:30 weekdays, and a lack of experience and confidence

limits participants’ ability to participate in communication or the delivery of PDS.

2. Compensation: Fair compensation for services provided by peers was an important factor

for those interviewed. Several indicated they would like to be regarded as equals to agency professionals

when delivering PDS.

3. Training: Many peers expressed interest in learning about and participating in training,

even though they may not see themselves in a PDS role. Participants mentioned particular interest in

workshops, retreats, and opportunities to meet others and learn more about HIV.

3.1.2 Front Line Service Provider Results

There were 22 responses from the Front Line Service Provider online survey, representing a wide variety

of organizations delivering a wide variety of services, including: support groups (46.2%), social media

meeting places (38.5%), a newsletter or magazine (38.5%), community events and education (69.2%),

BBI Chronic Health Navigation (38.5%), harm reduction (84.6%), and outreach (69.2%).

Experiences with models of PDS by front line staff revealed the following activities: peer leadership

training among staff, training volunteers to accompany prevention education coordinators, peer-led and

peer-facilitated support groups for HIV and HCV, harm reduction outreach, informal peer support groups

for MSM, and health navigation.

76%

24%

Would you be interested in Peer Leadership Development opportunities?

Yes

No

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In regards to the strategies laid out in the “From Hope to Health towards an AIDS-free Generation”

document, and to support the STOP HIV campaign, front-line service providers felt that peers can

contribute towards achievable outcomes in the following ways:

encouraging people at risk to engage in testing

sharing their experiences and local perspective

providing supports to those newly diagnosed to overcome barriers to services (health navigation)

encouraging harm reduction practises, including testing

practicing confidentiality with the newly diagnosed for increased trust and safety

providing passive remote supports

providing assistance with acceptance and coping with a new HIV diagnosis

engaging in prevention and delivery of education

conducting peer-led support groups

engaging in self-advocacy,

increasing service consumption of underutilized programs

providing life-skills training

helping to normalize HIV and assist with stigma

encouraging the newly diagnosed to engage in workshops and leadership training

Three salient themes emerged from survey responses and discussions with front line service providers

regarding effective delivery of PDS: components of success, challenges and barriers, and core leadership

development.

Components of Success

According to front line service providers, populations that would be best served by having peer delivered

service/navigation would include:

all who are positive

individuals who are marginalized

those with HCV or at-risk

First Nations peoples

non-English speaking people

women

the GLBTQ population

those who are reluctant to engage yet need ongoing support

those who are having difficulty accepting their diagnosis

youth

the street entrenched

the formerly or currently incarcerated

anyone that could benefit from culturally specific peer navigation

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Front line service providers also described the benefits for peers participating in PDS. These benefits

include:

empowerment and inclusivity to the fostering organization

feelings of validation

increased trust and access to those using drugs

connection to the MSM community

improved access and engagement with health care and related services

enhanced perceptions of safety (for example, peers providing testing and health promotion at

Shambala music festival made drug users feel safer about approaching them)

a collective voice at the municipal, regional, provincial, national, and international level

improved health outcomes

autonomy in relation to making a difference for people using drugs

reduced fear, stigma, and discrimination

a sense of participation and ownership

the development of effective strategies for living healthy lives

Best practices identified by front-line service providers included ongoing education and supervision,

provision and access to peer leadership training, appropriate and fair compensation for services rendered,

awareness and adherence to organizational mandate, policies, confidentiality and safety, development of

trust, inclusion and respect shown by paid non-peers, communication skills and techniques, a healthy

understanding of boundaries, and appropriate HIV and HCV education.

Challenges and Barriers

According to front-line service providers, populations least served by current models of PDS include:

those who do not wish to disclose their HIV or HCV status

those in rural areas (due to implementation barriers)

all people at risk

remotely situated indigenous populations

more advanced socio-economic demographic groups who are reluctant to access ASOs

youth

people who are positive with HCV

Front-line service providers were asked what some of the challenges have been in implementing PDS.

Challenges include:

long distance consultation and extreme travel

lack of PDS already in place

difficulty obtaining doctors

accommodation and transportation

lack of funding for peer specific programming

loss of peer leaders due to attrition, illness, relocation, travel issues, and life circumstances

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building trust and authentic care

lack of follow-through on programming once started

training and supervision

peers in their role as volunteers not conducting themselves in a way that aligns with the values

and ethics of the organization they are representing

communication and mental health barriers impeding peer participation with front-line staff

reliance on volunteer work (tokenizing and opportunistic) vs. paid work (honoring and

empowering)

triggers for addiction or relapse

stigma and discrimination

lack of subsidized housing

limited access to meal replacements or appropriate nutrition

Respondents also noted that, while Intelehealth may support individuals in reducing travel and financial

barriers, it is not a stand-alone solution because it is not universally available.

Beyond the challenges of implementing PDS, respondents also discussed other potential barriers to

successful delivery of PDS:

inequity of medical services, testing sites, post-counselling sites, walk-in clinics and GPs

peer readiness and/or lack of supports

education

peer leadership training and funding

the difference in needs between rural and urban communities

distance between people and services

lack of transportation, particularly during extreme weather conditions

Remotely delivered support was identified as a challenge because most people do not have Internet or

reliable computer access.

Core Leadership Development

Emerging from the components of success and barriers noted above were several key elements of core

leadership development for the delivery of PDS. These elements are: various peer leadership programs

offered by PAN and Positive Women’s Network, Red Road and PLDI as well as delivery of support

service awareness, training in areas such as computer literacy/access, trauma, mental health, substance

use, boundaries, confidentiality, self-care, health navigation, community and provincial resources,

QUEER competency training, cultural sensitivity training, communication skills, and ethical

responsibilities. Training in Pre- and Post-test counselling, First Aid and CPR, and Naloxone were also

noted as critical for organizations employing peer mentors.

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3.2 Study Implications

3.2.1 Implications for Peer Mentors and the Newly Diagnosed

This inquiry holds several important implications for peer mentors and the newly diagnosed.

The results of this process suggest that PDS is reciprocal and typically based on personal commonalities

and friendship. Personal commonalities need not necessarily include HIV status; indeed, peers can come

from outside the HIV community. An example from this inquiry is an HIV-positive man living in a

rooming house who identified one of his supporting peers to be a roommate and drinking friend.

Although his friend is not HIV-positive, the two provide valuable support to each other through

friendship. A further example is a man who disclosed that he is HIV-positive and identifies as gay and has

a peer support who is an HIV-negative gay male. In this case, the personal commonality is not HIV status

but rather identification as gay men in a rural community.

While they noted potential power differentials or others concerns, peers indicated they would value

financial compensation for their contributions to a PDS model.

When asked how they would respond if given a choice between having either a professional advocate or a

peer mentor to assist with improving quality of life, most survey respondents chose the professional

advocate. Assistance provided by the professional advocate included being able to facilitate

communication with government Ministries and health professionals. Those consulted considered this

approach of greater benefit than a peer advocate, unless the peer has had some professional training or

experience. The data suggests that peers trust the level of care provided by professional advocates and

front-line workers due to their capacity to provide non-judgmental service irrespective of association with

specific populations.

It is evident that peers who live in larger communities enjoy access to more support services. Because

they may already have a team of professionals to advocate for them, the idea of a peer mentor is

attractive. People living in small, rural, or isolated areas have fewer options for support and so it is more

important for them to have a professional advocate to assist with their continuum of care.

Most peers who live in rural communities have chosen to live in those communities, often because they

appreciate their privacy and natural surroundings. According to participants, living rurally should not

result in an inequity of services and access to programs.

For a peer to become a mentor and take on the ethical care of someone newly diagnosed, that peer must

have his or her own needs met first. Many of those interviewed indicated that they continue to struggle to

meet their own needs; these needs would potentially hinder the ability to provide consistent, concentrated,

and empathetic care to another.

Peers who live in rural regions may be limited in regards to the kind of services they could provide. Very

few individuals surveyed owned a vehicle that was insured all year, and travel in the winter months could

cause stress and danger to both parties.

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3.2.2 Implications for IHA and Organizations Providing Services

In creating a PDS model we must ensure that “we do no harm” to a) the peer mentor, b) the newly

diagnosed peer, and c) the organization supporting both peers. Readiness for PDS will come as a product

of increased support of individuals living positive. This means that increased support in the continuum of

care is essential. By improving housing options, nutritional supports, medical access, and mental health

services, peers can gain greater stability and therefore greater ability to contribute to any PDS model.

Nevertheless, there is a role for peers to contribute in PDS throughout the continuum. For example, peers

can

participate in the distribution of harm reduction services,

create and contribute to drug-user initiatives and support groups,

contribute in peer-led and or professionally-led peer-delivered support groups,

provide referrals and encouragement for those at risk to pursue testing and treatment, and

help deliver education, in conjunction with a professional educator.

These delivery options can be implemented by local agencies that have existing relationships with clients

who might show interest.

Overall, this process demonstrates that it is not safe to assume that peers will naturally demonstrate a need

or desire to participate in Peer Delivered Service. Rather, the ongoing needs of peers may often outweigh

their ability to take on additional responsibility for the well-being of others. As one peer stated: “I live

with HIV twenty-four hours a day, seven days a week, and the struggle is constant.” More support for

those who are HIV-positive is required within the Interior Health Authority to support ongoing

stabilization, ultimately encouraging further engagement in the provision of Peer Delivered Services.

3.3 Study Limitations

This inquiry and its findings face a few key limitations:

1. The inquiry was originally conceived as a three-month project, but the Christmas holiday season

meant that many agency personnel were on holidays during the data collection stage; email and survey

responses came back slowly, and it was difficult to engage some agencies, groups, and individuals at this

time.

2. The tight project timeframe did not allow time to build a Peer Advisory Committee, which would

have been beneficial in all stages of the project.

3. Some areas within the IHA were not able to participate, for one or more of several reasons:

lack of service provider

lack of a local lead person to connect the Project Facilitator with peers

time limitations

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Communities that were thus not included were: Golden, Revelstoke, Barriere, Clearwater, and several

First Nations communities.

4. The Peer-Client Survey failed to identify subpopulations by ethnicity, gender, age, and sexual

identification/orientation.

5. Non-marginalized peers may be underrepresented in the data because most participants were

referred to this project by front line service workers of an ASO or organization that provides support to

marginalize populations.

4. RECOMMENDATIONS

4.1 Study Recommendations

This inquiry on Peer Delivered Services supports several key recommendations for the Interior Health

Authority:

1. Funding should be given to ASOs and other agencies in the Interior Health Authority region to

provide support to peers living with HIV. This funding would support crisis grants in the form of grocery

cards, transportation allowances for medical appointments, and nutritional supplements.

2. Agencies should make concerted attempts to provide people living positive with opportunities to

engage in core leadership development and services.

3. Funding should be provided to train people living positive who demonstrate an interest in

developing core leadership. This could include contracting facilitators to visit different regions, providing

training and workshops hosted by ASOs, and providing honorariums for volunteers Peer Delivered

Services.

4. Strategies should be developed to support individuals living in remote communities through

telecommunications and the Internet. Furthermore, to reflect the diversity of the region, strategies should

be explored to ensure input from remote populations regarding the planning and delivery of HIV services.

5. Multiple PDS approaches should be explored, since a singular PDS approach may not be suitable

for all communities within the IHA.

6. A region-wide Peer Advisory Committee should be developed to a) serve as an active and

ongoing vehicle for peers to contribute their voices to peer involvement in program services, and b) make

future recommendations on PDS within the IHA.

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4.2 Organizational Implications

There are significant challenges to involving peers in the delivery of services to newly diagnosed

individuals. Some peers in the region continue to struggle with issues of poverty and basic self-

management and may not be able to participate in direct service to others. One option to consider based

on this inquiry is to provide funding support for peers to access support for basic needs such as food,

rental support, and emergency health needs. This would be delivered by agencies that offer HIV support

services in the region. Organizations would need to encourage service users to participate in an advisory

committee to help guide the services in the region. Organizations would also need to make available

opportunities for training, skills building, and life skills training.

Populations affected by HIV are diverse, differing in terms of transmission routes, lifestyle, age, gender,

ethnicity, as well as socio-economic status. Developing a single model for peer delivered services for the

region may not meet the needs of the different regions and subpopulations within the IHA. Agencies

should consider contributing additional financial resources to support leadership training opportunities for

those living with HIV to be better prepared to respond to the needs of newly diagnosed individuals living

within the Interior Health Authority.

4.3 Recommendations for Future Inquiry

The limitations of this project, as outlined in Section 3.3, suggest two primary areas of future study: 1)

HIV-positive individuals in the region, particularly outlying regions underserved or unserved by ASOs,

should be consulted regularly or involved in program and service delivery decisions; 2) distinct

populations such as First Nations communities within IHA could be consulted to further contribute to

planning for PDS that maybe developed in the region.

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APPENDIX A - British Columbia Interior Health Authority

http://midwifery.ubc.ca/student-portal/midwifery-clinical-placements/about/interior-health/

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APPENDIX B - Peer-Client Survey Tool

Peer Delivered Needs Assessment for Stakeholders Thank you for your time in advance. This survey is a very important part of the needs assessment that we are conducting over the next 2 months. Interior Health in partnership with the ASK Wellness Society, ANKORS and Living Positive are seeking direction and information from the positive community within the Interior of BC so that recommendations can be made about how to implement a peer delivered service program. "Peer Delivered” service means that individuals who are positive would provide supports to individuals who have been newly diagnosed with HIV/AIDS. By sharing their knowledge, experience and resource information newly diagnosed clients may be more likely to have a seamless transition into receiving supports. This project seeks information about what the challenges are for someone who is living positive in a rural region and what are some of the successes for peers who are engaged in peer support programming. Your input is by far the most valuable and we hope to represent the voices and needs of both rural and urban demographics so that one model of peer delivered service can be accessed throughout the Interior Health region. Inclusiveness, equal access and client driven care are the main objectives of developing this model of service. For more information or to book an interview please contact Kira Haug email: kira@askwellness.ca 1.250.574.7529

Are you a peer (individual who is HIV+) or peer service provider (service provider who is HIV+) or other

stake holder (an individual with a vested interest of life experience with the HIV+ community)?

Peer

peer service provider

stakeholder/other

How long has it been since your diagnosis for HIV?

1 year or less

5 years or less

10 years or less

more than 10 years

In what community do you reside?

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What agency/agencies do you access for supports?

Do you live in a rural community and experience a lack of access to services?

Yes

No

If you answered yes to the last question, what services would be helpful in improving your quality of life

and access to care services?

What programs or services are you engaged in currently?

BBI Heath Navigation (working with a service provider that assists with your medical needs)

Support Group (support group or meeting for positive people)

Harm Reduction Services

Life Skills Training

Employment Programming

Housing

Outreach

Other, please specify... ______________________

Have you ever been or currently are engaged in a model of peer delivered service? If so what kind?

examples; Peer lead Support Group (group lead by a person who is positive) or Peer Delivered Health

Navigation (support in a hospital setting by a person who is living )

Have you engaged in a model of peer delivered service and found that it did not meet your needs? If so,

what kind of service was that?

25

Would receiving support services from a peer support worker (a program support worker who is living

positive) be more desirable than a non- peer?

Yes, I would prefer a peer.

I am comfortable with a peer or non-peer delivering professional support services.

I don't know.

other please specify. ______________________

Would you be interested to learn more about opportunities or access to training and supports to

becoming a "peer" who delivers support services to other peers?

Yes

No

In the continuum of care (the multiple areas of one's life that might require support services while living

with HIV) what are the most important services that you think should be easily accessible to all

individuals regardless of where they live (rural or urban centers)?examples; access to testing, education,

financial supports, housing, mental health services, addiction services, employment opportunities.

What do you think the benefits would be of peer delivered services?

Can you identify any barriers or challenges that may arise in a peer delivered service program?

examples; consistency in support or client confidentiality

Would you be available for a phone/Skype or face to face interview (confidential) to discuss the concept

of peer delivered service in more detail? I will be traveling through the BC interior in the month of

January to visit agencies, staff and peers/stakeholders.

No

yes- please describe what would work best for you ______________________

Individuals who wish to participate in a face to face interview would be given an honorarium for their

time. What would you prefer to receive for a 1-2 hours of your time?

*snacks and beverages would be provided as well

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grocery gift card

cash

I have no preference

Is there anything you would like to add that may have been missed on this survey?

Thank you for taking the time to participate in this survey. I look forward to reading your responses. For

more information or to schedule a visit please do not hesitate to contact me. Kira Haug 250.574.7529

kira@askwellness.ca

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APPENDIX C - Front Line Service Provider Survey Tool

Peer Delivered Services Needs Assessment

This survey is part of a 3 month Interior Health Region initiative being done to collect and provide

recommendations so that a peer delivered service model can be implemented. This needs assessment

survey will contribute to the direction of this process by connecting to the professionals and service

providers supporting the HIV/AIDS community within IHA. We hope to get a sense of what is working in

models of peer delivered services. What have been the successes, challenges and gaps for individuals

utilizing these services? Following this survey there will be a 2nd survey (anonymous and confidential)

for peers/clients and stakeholders. We hope to achieve an understanding of your organizational

experience around peer driven service and strategies for engaging the clients in your programming.

Thank you in advance for your contribution and expertise. (Question 5 refers to the document "From

Hope to Health Towards an AIDS-free Generation" by the Ministry of Health. Question 10 refers to the

STOP HIV/AIDS initiative. https://mail.askwellness.ca/owa/redir.asp_infosheetv04dec2013.pdf

Hope to Health - http://www.health.gov.bc.ca/library/publications/year/2012/from-hope-to-health-

aids-free.pd STOP HIV-https://mail.askwellness.ca/owa/redir.asp

What is your title and service area? Please describe the peer support approach your agency has used?

Using a peer model what have been the successes you have encountered?

What have been the challenges?

What are some best practice supports that could be identified between peers and clients in peer service

delivery?

What role do you believe peers have in achieving outcomes in the "From Hope to Health Towards an

AIDS-free Generation" initiative? What do you think is achievable and in your opinion how would you

do that?

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What types of peer delivered services is your agency/region participating in? Select all that apply

Support Groups

Social Media Meeting Places

Newsletter or Magazine

Skype or Telehealth support services

Community Events and Education

BBI/Chronic Health Navigation

Harm Reduction

Outreach

Other ______________________

We are looking for peer engagement from your region to define this process and the outcomes. What

would be the best way to connect with peers/stakeholders/clients? Select all that apply

social media

Skype interactions

face to face interviewing

working group interviews

telephone conferences

survey by email or in person

other ______________________

Would your agency and its relevant programs be available for a scheduled visit in your region next

month? Would it be possible to arrange a morning working interview (and or face to face) with the

service providers and another for peers/clients/stakeholders in the afternoon? Who would be the key

contact?

Consents forms and confidentiality agreements will be part of this process. Honorariums would be

provided for the peers/clients/stakeholders in exchange for their time. Light snacks and refreshments

would be provided as well.

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Was there ever a time where one of the above peer delivered services was implemented in your region

and then disabled? If so, what service and why?

How do you think peers can support the STOP HIV/AIDS campaign?

Are there populations that would be best served by having a peer navigation program?

What populations are least served by current models providing peer delivered services?

What training and supports do you think need to be in place for peers providing these services?

How often has your agency heard from peers/clients wanting more peer services? Which specific

services are requested most frequently?

Please feel free to include any comments you might have or suggestions you would like to contribute

here.

Thank you for taking the time to participate in this survey. The results will help develop a

peer/stakeholder/community member (anonymous) survey that will be available through multiple

resources. During the month of January I will be touring the B.C. Interior to visit agencies, programs and

individuals for face to face and working group interviews. I can be reached at 250.574.7529 or

kira@askwellness - Kira Haug, Health Services- ASK Wellness Society

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APPENDIX D - Confidentiality/Consent Form

Peer Delivered Service Needs Assessment

Consent Form

____________________________________________________________________________________

I give permission to Kira Haug to share the information given today with Interior Health and service

providers for the purpose of developing Peer Delivered Services. My name will not be included and all

survey /interview results collected today will be anonymous.

*NOTE: You may withdraw consent at any time by informing Kira Haug.

Peer’s Name: _______________________________________

Peer’s Signature:_____________________________________

Kira Haug:__________________________________________

Date:___________________________

Kira Haug

433 Tranquille rd

ASK Wellness Society

Phone 250.574.7529

kira@askwellness.ca