Point-of-Care HIV Testing Among Winnipeg’s Homeless

Manitoba has some of the highest per-capita rates of human immunodeficiency virus (HIV) in Canada. Each year there are approximately 80–120 newly diagnosed cases in the province—population 1.272 million as of January 2014—with many of them discovered in the capital city of Winnipeg (699,346 as of July 1, 2013). Worse yet, the Public Health Agency of Canada estimates 28% of HIV infections in Canada remain undiagnosed.

At particular risk are the city’s homeless and transient population. It’s not just that this demographic presents a higher risk of HIV infection due to unprotected sex and shared intravenous needle use; their low status on the socioeconomic ladder also makes them less prone to actively seek out medical care and sexual health services. As well, those who are willing to seek testing may be deterred from doing so for fear of public embarrassment due to the quality of their clothes and/or appearance. Even a government-funded free health service is of no use if those who need such help don’t access it.

Add the fact that HIV testing rates in Manitoba are low and that traditional strategies such as STI clinics do not capture those patients who aren’t seeking specific sexual health services, and clearly a new strategy was called for. This is why the Manitoba HIV Program decided to pursue an innovative approach to increasing early HIV testing and linkage to care—and has done so with success.

Winnipeg paramedic Ryan Sneath plays a central role in helping this innovative approach deliver results among the city’s most vulnerable citizens. Currently working as the Winnipeg Fire Paramedic Service’s Winnipeg Regional Health Authority liaison and director of community paramedic programs, Sneath spearheads fast-results HIV testing at the Main Street Project (MSP), a homeless center and detox facility in downtown Winnipeg.

“In 2013 the Winnipeg Fire Paramedic Service partnered with the Manitoba HIV Program to test high-risk individuals for HIV, link them into care and retain them in care,” Sneath explains. “This program leveraged the existing relationship the WFPS Community Paramedic Program had developed at the Main Street Project, which houses some of the most vulnerable individuals within Winnipeg.” The MSP includes the city’s intoxicated-persons detention area, a detoxification unit, a homeless shelter and a transitional living area. The MSP houses approximately 150 vulnerable individuals at any given time.

The idea behind this HIV mitigation project was to test Winnipeg’s homeless and transient population on their own turf. Focusing on this group makes sense: “All of the top risk factors for contracting HIV in Manitoba are prevalent within the MSP,” Sneath says. “The risk factors, combined with the transient nature of this homeless population, make them the ideal group to receive this type of screening.”

The blood tests are done by Sneath and one other paramedic who is known to these people. They perform them using a form of HIV screening test that can be done quickly and does not require any follow-up visits by the clients.

Specifically, the project uses bioLytical’s point-of-care INSTI rapid HIV-1 antibody test, “which has been approved by Health Canada and has 99.6% sensitivity and 99.3% specificity,” says Sneath. “The test requires a small amount of capillary blood, and clients receive the results within 1–2 minutes of testing.”

If a test’s result is negative, the paramedics provide the clients with appropriate sexual health education and offer them retesting in 3–6 months. If the result is positive, the client is counselled and referred to Nine Circles Community Health Centre. At this clinic clients are immediately connected to care and provided with follow-up and specialist services if needed.

To allay clients’ fears, testing at the MSP takes place during common patient encounters and has, in fact, become a part of the daily care the paramedics offer here, thus reducing clients’ anxiety levels. Paramedics also host monthly testing fairs at the MSP and encourage local community members to participate.

The success of this Winnipeg HIV screening program is built upon the trust the paramedics have earned among the MSP’s clients. “Independent research has shown that 33% of the population at the MSP do not like visiting traditional health centers and would much rather receive care from a provider they know,” says Sneath. “Access to medications has also been of great concern for this population, and this is the reason many of them are noncompliant with recommended treatments.”

Since the MSP’s HIV screening program started in October 2013, the two paramedics have tested nearly 1,500 patients for HIV and have newly diagnosed four patients. The paramedics have also utilized their established therapeutic relationships to get four other patients previously diagnosed with HIV back into treatment.

“The paramedics monitor all of these patients’ medication adherence, and they ensure the clients are greater than 95% compliant,” Sneath notes. “When patients are greater than 95% compliant with their medication regime, the HIV virus is ‘put to sleep,’ and the chances of transmitting it are very slim.”

The success of the MSP HIV screening process is motivating the WFPS to expand this program into other areas of Winnipeg. “Paramedics in remote settings could utilize this as a rapid screening tool too, but they must have the ability to link the patients with the appropriate care teams,” says Sneath. 

James Careless is a freelance writer with extensive experience covering public safety.