APPENDIX 6: VISIT TO LEEDS 9 MAY 2011
The Committee visited a needle supply programme,
Leeds General Infirmary and two community service providers in
Leeds. Lord Fowler, Baroness Gould of Potternewton, Baroness McIntosh
of Hudnall, Baroness Masham of Ilton, Lord Rea, Baroness Tonge
and Professor Anne Johnson (Specialist Adviser) were in attendance.
The Committee would like to thank all of those personnel
named throughout this note for their work in arranging activities
on the day, and for their time in providing information to the
Committee.
A. Needle supply programme
The Committee visited a needle supply programme located
in the city centre. The facility was provided as a specialised
service in the basement of a Boots pharmacy, supplying
clean injecting equipment and methadone. Supply of methadone required
a prescription and participation in a drugs treatment programme;
supply of injecting materials did not. There was no requirement
for service users to be registered with a local GP practice or
health service.
Before receiving injecting equipment, users were
required to complete a form outlining their requirements and specifying
what the materials would be used for. The form had been designed
with input from service users. The overall number of injecting
drug users in the city had declined in recent years. The large
majority of those accessing the city centre facility were heroin
users; other needle supply facilities in the city had, however,
seen increased numbers of steroid users accessing services in
recent years.
Service users were encouraged to return used needles
in exchange for new ones, but this was not mandatory. This approach
was part of the harm reduction ethos of the service; the pharmacy
existed to reduce the sharing and repeat use of needles, rather
than to act as a pure exchange service. The free availability
of needles and equipment also meant that they had very limited
resale or cash value.
The approach pursued within Leeds had been successful:
there were fewer than 10 injecting drug users with HIV within
the city. Locating the facility in Boots had been successful
in reducing stigma and enhancing accessibility.
Although there had been problems initially with anti-social
behaviour, the store had developed its needle exchange provision
into a more specialised service in the downstairs of the store,
which had improved relations between users of the service and
general customers. It had shifted from being a store which was
'black marked' by national management to a successful enterprise.
B. Leeds General Infirmary
Epidemiology
Dr Mike Gent, Director of the West Yorkshire
Health Protection Unit, gave a presentation on the epidemiology
of HIV in the area. In 2009 there had been 391 new HIV diagnoses
in Yorkshire and the Humber; this represented a 255% increase
from 2000 levels. 56% of the diagnoses were classified as late
(a CD4 count at diagnosis of less than 350 cells per mm3
at diagnosis) and 32% were very late (a CD4 below 200 cells per
mm3).
HIV was more prevalent in urban and deprived parts
of the region; areas showing increased prevalence over the past
decade had a strong correlation to those areas which had received
dispersed asylum seekers. Over 50% of the local HIV-positive population
were heterosexual black Africans, although the greatest percentage
increase in diagnoses over recent years had been amongst white
heterosexuals.
The geographic variation in prevalence was also of
note. Although Leeds overall had a prevalence below 2 per 1,000—the
rate at which national guidelines recommend expansion of testing
programmes—there were areas within the region where prevalence
exceeded that level. There were questions, therefore, around how
testing expansion was to be approached in the light of this variation.
However, monitoring of new diagnoses showed that
rates of recent infection were higher amongst men who have sex
with men, with more than 50% of those newly diagnosed in Leeds
and Sheffield recently infected. This suggested higher levels
of new infections amongst that group. It was imperative to continue
the roll-out of RITA testing in order to better understand transmission
patterns.
A significant proportion of the patient cohort was
aged over 50. Given the increased levels of vascular and neurocognitive
issues in this group, the engagement of GPs in their care was
crucial.
North and West Yorkshire HIV Network
This was followed by a presentation from Dr Eric
Monteiro, a consultant in Genitourinary Medicine at the Leeds
Teaching Hospitals, setting out the work of the North and West
Yorkshire HIV Network. The network was centred around 'principal
treatment centres'—Leeds had been 'pre-designated' as one
such hub. Facilities in York, Scarborough and Wakefield acted
as satellite units, referring complex patients to the centre and
utilising centralised expertise in patient management.
The network, established in 2010, provided services
to over 2,200 HIV positive patients across these centres. Joint
service and care specifications had been developed, and the network
provided a forum to share expertise and facilitate joint working
across the region. Unlike other similar care networks, however,
the HIV network had no identified funding stream or administrative
support. Funding levers were required to more firmly establish
the model, particularly in the light of concerns over commissioning
reforms.
It included representatives from hospitals, public
health services and commissioners, as well as community and patient
organisations, and had developed a number of protocols for care
and agreed work streams for use across the network. These work
streams covered areas such as early diagnosis in acute settings
and community HIV testing, as well as pre- and post-exposure prophylaxis.
The representation of community groups sought to engage the network
with prevention issues as well as those around treatment. Primary
care needed to become more engaged and involved in the work of
the group.
HIV care in District General Hospitals
Dr Lindsay Short, GUM Consultant for the Calderdale
and Huddersfield NHS Foundation Trust, spoke about the nature
of care provided in smaller centres.
Positives
District hospitals offered a number of advantages:
for one, services could be provided closer to patient's homes;
and owing to smaller team sizes, strong patient-clinician relationship
could be developed. Indicators, such as high levels of patient
retention, suggested high levels of patient satisfaction. The
development of the North and West Yorkshire HIV network had built
upon these strengths, developing clinician links that allowed
the discussion of difficult cases and supported patients if they
needed to be transferred to more specialist facilities.
Challenges
Delivering care in district settings was not without
challenges. There had been a rapid increase in the cohort: Huddersfield
Royal Infirmary had gone from 24 patients in 2001, to 182 in 2007
and 330 in 2011. This brought pressures for a small clinical team,
which had not enjoyed a corresponding increase in resources or
capacity. A policy which discouraged consultant-to-consultant
referrals only made this worse. Furthermore, not all district
settings had access to a HIV pharmacist or psychosocial services,
both of which were essential to providing effective care.
In logistical terms, the provision out of hours care
was also sometimes difficult, and IT support was insufficient
to cater for service innovations. There were also problems around
the transparency of budget provision.
The development of the regional HIV network would
be vital in allowing North and West Yorkshire to respond to these
challenges. It would allow patients to continue to receive their
care as close to home as possible, whilst also developing capacity
across different centres and facilities. It was unclear how proposed
NHS reforms would impact upon this evolution of services.
There were also concerns around any over-centralisation
of specialist care. It was important for clinicians in district
hospitals to continue to be exposed to and deal with complex and
specialist cases, in order to develop their knowledge and skills
around HIV. As well as this, GPs had to be encouraged and reassured
about involvement in patient management, and patients encouraged
to involve primary care in their treatment.
Sexual Health Research in York
Dr Fabiola Martin, Senior Lecturer in HIV Medicine
at Hull York Medical School briefly presented information on current
HIV research initiatives. The school was currently involved in
a number of research initiatives focused upon prevention methods,
including microbicidal gels, rings and mucosal vaccines, as well
as research aimed at better understanding the activity of antiretrovirals.
Future research planned in the centre included oral antiretroviral
HIV prevention studies in MSM and more detailed work upon anti-HIV
microbicides.
It was important to understand the effect and performance
of these initiatives upon women, who were at greater risk of STI
acquisition and were often disempowered within sexual relationships.
Research also highlighted the difference between efficacy and
effectiveness, with major differences between perfect and typical
use of most prevention interventions.
Management of HIV at Leeds Teaching Hospitals
Dr Jan Clarke, Consultant in Genitourinary Medicine,
gave a presentation on how HIV was managed at the hospital.
Workload
The patient cohort at the hospital had increased
from 271 in 2002 to 1137 in 2010, a 195% increase. Around 70%
of patients were dealt with in GUM services, with the rest dealt
with as part of the infectious diseases cohort. Care for young
people and families, as well as antenatal care, were areas of
priority, but so were the challenges thrown up by an ageing HIV
cohort
Staff profiles
There were three categories of staff involved with
HIV services at the hospital: HIV-specific staff, such as clinical
nurse specialists, pharmacists and midwifery coordinators; staff
with HIV specific components in their job plans; and supporting
staff, including health advisers involved in partner notification.
Service configuration
The Trust was one of four designated centres for
complex HIV care in Yorkshire and the Humber. This was part of
the development of a HIV network within the region. Spending on
HIV was around £10m per year—around 1% of an overall
£1bn Trust budget.
Service delivery was split over two sites, located
15 minutes apart. Outpatients were dealt with at Leeds General
Infirmary, with HIV inpatients and infectious diseases outpatients
dealt with at St James's This disconnection made service provision
more difficult and merging was an issue to be discussed.
Given the development of a network, it was imperative
to work more effectively in combination with services elsewhere.
Virtual clinics, where clinicians could share their expertise
via telephone or online, was one potential development. Another
was the establishment of pathways to devolve care elsewhere, with
specialist oversight. To do so, however, required a more effective
IT network than existed at present. Across all areas, it was important
to improve the patient experience to ensure engagement with services,
for example through greater availability of appointments.
Benchmarking
There were a number of methods by which services
were benchmarked. At PCT level, there was a CQUIN commissioning
benchmark regarding access to care, and services were audited
in line with BHIVA standards. Both demonstrated that services
were effective. At a commissioning level, the Yorkshire and the
Humber Specialised Commissioning Group benchmarked services through
the use of year of care tariffs, common standards and care pathway
agreements.
Clinical issues
Access to testing
It was important to increase access to testing services,
especially in non-specialist settings. Staff, not patients, had
been shown to be the barrier. To effect change, it was important
to gain the support of team leaders to influence behaviour throughout
the hospital.
A poster campaign was underway within the hospital
aimed at acute medical staff, and influence was brought to bear
on staff from elsewhere in meetings with other departments. Staff
hoped that this would boost testing levels when patients presented
with indicator diseases, an area for improvement which could reduce
levels of late diagnosis.
Partner notification
Partner notification was an important strand of prevention.
However, it was a difficult area to secure resources for, as there
was no standard metric by which to audit the work done. Nonetheless,
it was an area that needed focus.
Capacity
Capacity was a problem. Despite increasing patient
numbers, it was felt that staff resources had not risen commensurately.
In 2011, for example, funding was only available to make use of
one of the unit's specialist pharmacists part-time. This increased
the pressure on staff.
Psychological services
Psychological care services were insufficient. It
was "amazing" that there was no in-house psychological
provision, given the role that such services could play in clinical
care.
Primary care
Expanding testing into primary care was important.
As part of those efforts, the Trust had established a website
offering leaflets and guidance for GPs, an important resource
for increasing familiarity with HIV.
Infectious Diseases at Leeds Teaching Hospitals
Dr Hugh McGann, Consultant in Infectious Diseases,
gave a presentation on how HIV inpatient services were managed
at the St James's Hospital facility, part of the Leeds Teaching
Hospital Trust.
Cohort
There were 374 patients in the cohort at St James's,
with an approximately even split of men and women. Most patients
were diagnosed late, often following a visit to the unit with
an opportunistic infection. More than 50% were diagnosed with
a CD4 count below 200 cells per mm3, and a significant
proportion of patients had a CD4 count below 50 cells per mm3.
Such patients were "extremely" expensive to treat as
a result of prolonged hospital stays.
Capabilities
The unit contained 18 beds, with four negative pressure
suites for the containment of infectious patients. It was staffed
by infectious disease consultants along with a specialist HIV
pharmacist and nurse specialist, and nursing staff with experience
of dealing with HIV infections. Staff met weekly alongside staff
from GUM services to discuss patient management.
HIV testing
Pilots into expanding HIV testing on the ward commenced
in January 2011. All patients admitted were offered HIV testing
on an opt-out basis, and the uptake rate was 98%. Staff hoped
that this success would lead to expansion of the policy into acute
medical settings. HIV testing was also offered to all patients
with active TB.
HIV and pregnancy in Leeds
Dr Alison Perry, Foetal Screening Coordinator,
outlined how HIV and pregnancy was managed at the Trust.
Cohort
In 2009, approximately 50 HIV-positive women gave
birth at the hospital; fewer than 10% of deliveries were by Caesarean
as a result of viruses in the bloodstream. Success was down to
monthly multidisciplinary team meetings where each patient's plan
was discussed and agreed. Peer interaction of this kind encouraged
staff learning and meant that the service could mature through
experience.
Challenges
Syphilis had emerged as an issue at the hospital.
As a result, its management had become an element of care to be
arranged and discussed as part of team meetings.
As well as medical challenges, there were multiple
logistical obstacles. Women often used multiple names to protect
their identities; and in contrast, there was evidence that a single
identity had been used by multiple women. Such practices, along
with dispersal of women to other areas, made close follow-up and
long-term patient relationships difficult.
Other issues were cultural. Communities often stigmatised
women who did not breastfeed; this posed an obstacle to best practice,
and the lack of milk tokens for women hampered efforts even further.
Women were also often fearful of partner notification, which further
inhibited prevention efforts.
Paediatric HIV services
Dr Amy Evans, Consultant in Genitourinary Medicine,
talked to the Committee about paediatric HIV services in Leeds.
There were 41 children or young people involved in the service
at present, of whom the largest proportion were aged between 11
and 15. Within the service, there was a paediatric consultant,
a paediatric HIV clinical nurse specialist, a paediatric pharmacist
and a GUM consultant. All staff were only involved part-time.
Children's HIV network
There was a well-established national clinical network
in the United Kingdom. However, Leeds was incorrectly classed
as a 'local centre', despite the fact its cohort was large enough
to classify it as a regional network 'hub'. If correctly designated,
the service would have more (and full-time) staff; as it was,
it was outgrowing its configuration.
Management of children
Services were delivered through two consultant-led
clinics and one nurse-led clinic each month. As part of those
clinics, a family and young person's service, transitional care
for young people and alternative access to HIV care and testing
were all offered. The primary challenge was providing the full
range of services with a staffing level "insufficient"
for the size of the cohort.
HIV testing
The hospital sought to get all children of HIV-positive
parents tested, as part of the Children's HIV Association campaign,
'Don't Forget the Children'. Although numbers were small—two
children out of 46 tested positive in 2010—staff asserted
the need to remain vigilant.
Developments
There were a number of developments in progress for
the service, centred on improving care for young people. An adolescent
forum, which sought to develop the provision of transitional care,
was one. Others centred on more flexible clinics, individual transition
plans for patients and broader guidelines for the management of
transitional care.
More broadly, there was close working between Yorkshire
and the Humber's HIV network and the Children's HIV National Network
to integrate services where possible. Collaboration of that kind
was essential for the unit, as a small service struggling to adapt
its infrastructure to an expanding cohort.
HIV clinical nurse specialist
Anna-Luisa Simonini outlined the role of the HIV
clinical nurse specialist in genitourinary medicine services at
Leeds. In Leeds, the nurse specialist ran a nurse-led clinic on
a daily basis. This involved, amongst other tasks, adherence management
of a diverse cohort of patients, sexual health screening and liaison
with the multidisciplinary team for onward referral where necessary.
Recent infection data at the Leeds Centre for
Sexual Health
Dr Sarah Schoeman gave a presentation to the
Committee on the results of a survey of rates of recent acquisition
of HIV in MSM attending the Leeds Centre for Sexual Health.
Recent infections
The Recent Infection Testing Algorithm (RITA) had
been introduced as a routine test for newly diagnosed HIV patients
from November 2009, and allowed staff to investigate trends in
HIV infection.
Results from 78 new HIV diagnoses over 12 months
showed that 35% of infections acquired from sex between men occurred
less than five months before the diagnosis. This was nearly twice
the UK average of 17%. Between August and September 2010, an even
higher proportion—56%—were recent diagnoses. For heterosexual
transmission, levels, at 2.6% (1 diagnosis out of 78) were below
the UK average of 7%. Amongst all those recently diagnosed, 43%
were co-infected with Chlamydia and 29% were co-infected with
gonorrhoea.
Such sophisticated data provided an opportunity to
take action amongst MSM where rates were disproportionately high.
Interviews with the cohort revealed common risk taking behaviours.
After liaison with the Health Protection Agency and Yorkshire
MESMAC, the Trust delivered materials to the local MSM population,
and continued to monitor RITA results. Use of such data to track
transmission trends and raise awareness of risk levels would be
important in future.
Question and answer session
Representatives from the hospital took questions
from the Committee across a number of areas.
Sex on premises venues
The Committee asked about tackling HIV transmission
within sex on premises venues. Staff noted that such venues were
increasingly private, a trend accelerated through the emergence
of social networking as a facilitator.
However, staff were keen to note that such behaviour
did not reflect MSM being 'jaded' around HIV. Instead, those infected
often led chaotic lifestyles or suffered from misconceptions around
risk. Lack of information—particularly in relation to 'serosorting',
where MSM sought out same-status partners—was a much greater
concern than any indifference to HIV.
Charging regulations
Clinicians were not positive about the concept of
charging for HIV care for those not lawfully resident in the United
Kingdom. They stressed that there was no evidence of health tourism,
and that it was treating patients was cost-effective for public
health reasons. As a result, it was the policy of the hospital
not to ask patients about their background.
Late diagnoses
The Committee asked about the implications of late
diagnosis. In response, staff highlighted the high rates of short-term
mortality, and the fact that the long-term prognosis was not as
good as for those diagnosed early. In addition, it was noted that
admissions following on from late diagnoses were also "very,
very expensive".
C. Leeds Skyline
Sinead Cregan, Adult Social Care Commissioning Manager
in Leeds, introduced a session with staff members at BHA Skyline,
a community organisation which delivered both HIV prevention services
for African communities and support services for a broad range
of those living with and affected by HIV. Those present included
Jeni Hirst, BHA Director of Sexual Health and Rebecca Bryan, Project
Coordinator.
Integrated services
The aim of Skyline was to commission support and
prevention services together, with pooled budgets to do so. Staff
felt that this integration had been achieved; funding was provided
by Leeds City Council for social support services, whilst NHS
Leeds part-funded preventions services tailored for African communities.
Support services
Support services began with an initial assessment
of need, following which a care plan was drawn up and subsequently
reviewed every 12 weeks. The service user then took part in interventions
aimed at meeting the needs outlined in the care plan. Interventions
took a variety of forms, from intensive one-to-one and group support
through to workshops, training and advocacy. Support was often
tailored; for example, there were specific work groups aimed at,
amongst others, women, black African MSM and young people. These
attended to physical, social and psychological needs.
Physical
Staff at Skyline "filled in gaps" that
consultants at the hospital did not have time to cater for, such
as complementary therapy for side-effects. In light of this role,
Skyline staff attended weekly meetings at the hospital to ensure
clear referral pathways through to Skyline (although referrals
also came from primary care and from walk-in patients).
Social
The provision of support for service users seeking
to return to work was a prominent element of Skyline's work; service
users present for the Committee's visit commented specifically
upon it. Support involved workshops around disclosure to employers
and CV and interview tips. Some social care needs, though, were
beyond the expertise of Skyline staff, and so referral to external
services providing housing, benefits or employment advice was
an important element of the overall package of interventions.
Psychological
Support was wide-ranging, including guidance around
disclosure, stigma and risk as well as community outreach work
to combat isolation. Confidence and skills were built up, improving
patient self-management. Work around adherence to antiretroviral
therapy was particularly significant, and users positively commented
on the help provided by Skyline in navigating clinical services.
Mental health services were prominent. Much of the
work was delivered through peer support, which feedback suggested
was more informal and personal. One service user referred to such
services as "invaluable".
Prevention services
Transmission profile
Over time, there was an increasing level of transmission
amongst black African communities within the United Kingdom. Although
the numbers of asylum seekers dispersed to Leeds had decreased,
there were still many students from African communities. It was
important to determine the level of transmission in this group,
as the increase in UK-based black African transmission demanded
a shift in how prevention services were organised.
Funding
Prevention work aimed targeted at African communities
was funded through the National African HIV Prevention programme,
Department of Health-funded national prevention programme commissioned
by the African Health Policy Network. Alongside general prevention
interventions, Skyline staff were funded to operate an HIV information
line for African communities.
Targeting
Although dispersal levels had fallen, there was still
a prominent African community in Leeds which required targeted
attention. Work was targeted at those living with HIV, people
in relationships where one partner was HIV-positive, those involved
in high-risk behaviours or partners of those who were.
Despite involvement in the NAHIP programme, staff
insisted that the targeted approach to prevention needed to be
considered in light of growing epidemics outside of African communities
and MSM. It was also important to think about young people, particularly
as new generations of immigrant communities became sexually active.
Aims
There were a number of aims for the prevention work
at Skyline: a reduction in the number of new HIV infections amongst
African communities; a reduction of the prevalence of undiagnosed
HIV; challenging stigma; and the empowerment of people to engage
with care to increase testing and treatment levels. Secondary
prevention—the prevention of onward transmission from those
already infected—was an important facet of such work.
Activities
Activities were delivered in the community; work
involved workshops and training, campaigns, information provision,
community events and skills building. Along with such capacity
building, the distribution of safer sex resources—in particular
condoms—was vital.
Model
Prevention interventions were guided by a NAHIP-produced
service model called The Knowledge, the Will and the Power
(KWP). It consisted of three strands: knowledge, which related
to information provision; will, which was linked to ending unsafe
behaviours by challenging societal norms, and outlining to people
the cost-benefits of avoiding HIV infection; and power, which
involved building up skills and confidence to allow people to
protect against HIV infection.
Barriers
Stigma was still a significant barrier to the delivery
of HIV prevention and support services. Work needed to be done
at all levels, as were social attitudes around issues such as
homosexuality, driven by cultural and traditional beliefs. More
practical factors in relation to immigration status and social
and economic circumstances—particularly the number of languages
spoken within African communities—also played a part.
Faith
Staff at Skyline had found it difficult to make inroads
into faith communities. Meetings had been organised with church
leaders and Skyline staff offered their services but often, especially
in Pentecostal churches, such offers were refused. There was much
work to be done, particularly around the reality of HIV and the
importance of adhering to treatment.
Funding
The local authority had been convinced to use its
entire AIDS Support Grant (ASG) allocation to support Skyline.
With lobbying from some commissioners within the local authority
and from those within the Skyline service, local authority provision
had increased from £70,000 when first funded to more than
£500,000 at the time of the visit. There were commitments
for both NHS and local authority funding streams to continue for
at least another two years.
Such support did not mean, though, that Skyline had
been immune from funding pressures. Funding for some physical
treatment services had been withdrawn by the NHS, and provision
was maintained only after social services commissioners provided
funding for what was traditionally an NHS competence.
National work
As well as the provision of regional support and
prevention services, Skyline fed into national evidence-gathering,
research and policy processes. As part of the NAHIP prevention
programme aimed at African communities, it also fed into the structuring
of prevention work nationally.
D. Yorkshire MESMAC
MESMAC was a community-based voluntary organisation
offering a range of sexual health services, primarily targeted
at MSM. These included the delivery of HIV prevention campaigns,
community based testing, group work, counselling, professional
training and outreach work. The organisation had multiple funders,
including the Department for Health-funded Community HIV and AIDS
Prevention Strategy (CHAPS). The service operated across Leeds,
Bradford, North and West Yorkshire.
Prevention
HIV prevention was delivered through a number of
channels. Of particular importance was group work, which allowed
members to reflect on common concerns and develop strategies to
promote safe sex. MESMAC operated a range of different groups
including sessions for black MSM deaf men, transgender people
and older men. The deaf men's group had been established to deliver
niche provision to a group who often had difficulty accessing
and interpreting mainstream prevention messages.
Group work was supplemented by campaigns in the local
press and through local gay media, as well as new delivery methods
such as podcasts. Recent campaigns had included adverts to promote
the use of post-exposure prophylaxis.
MESMAC also ran a dedicated project (entitled BLAST)
which sought to support young men and boys at risk of being sexually
exploited. This programme, which dealt with 3,000 people each
year, had been established as a response to growing concerns about
the use of internet sites to exploit young people. The programme
consisted of school visits, promotional materials and online content.
Outreach
Outreach work was intended to promote services, such
as community testing, in environments where service users felt
comfortable. In addition, outreach work sought to meet the needs
of those who 'fell through the net' of existing provision. MESMAC
was involved in outreach work in clubs, saunas, public sex environments,
prisons and churches.
Through direct engagement in these settings, the
community and voluntary sectors could add value to the work of
health and professional services. Outreach also provided a channel
for immediate feedback and evaluation of services, given the direct
engagement with service users.
MESMAC staff were asked about prevention work in
prisons. They said that the nature, extent and success of work
varied enormously, according to the approach of individual governors
and the culture of different prison settings. Some prisons had
condoms freely available on wards; others provided them only after
an approval process. No needle exchange facilities, to their knowledge,
operated in prisons. To support health promotion work in prisons,
MESMAC had recently produced a DVD toolkit for prison officers,
to assist them in dealing with HIV.
Testing
MESMAC offered community-based testing at a city-centre
venue. This was primarily aimed at MSM and operated on a self-referral
basis, with a Thursday evening drop-in clinic and an 'as and when'
service for the remainder of the week. Tests were delivered by
non-clinical staff and results were available within 20 minutes.
One advantage of delivering tests in this setting was that non-clinical
staff typically had a greater amount of time available for both
pre- and post-test discussions, as well as health promotion advice.
A service user who had tested positive for HIV gave
an insight into his experience of using the service. He had felt
more comfortable going for a test in a community setting, believing
that it would be easier to discuss his circumstances and background
with non-clinical staff. After testing positive, he had found
the post-test support from MESMAC "invaluable", allowing
him to consider his health needs and develop an approach for discussing
his condition with family and friends. He had also been supported
in dealing with employers who had terminated his contract following
ill-health post-diagnosis.
Counselling
MESMAC had access to 32 qualified counsellors covering
the whole of North and West Yorkshire. Spot purchasing arrangements
for this support allowed them to buy time from different counsellors
as and when required. This made for a flexible service, allowing
them to respond to the individual needs of different users. The
approach was in fact so flexible that counselling could be provided
in six languages, including British Sign Language.
Conclusion
Health promotion around HIV had become more difficult
over the past 20 years, as the condition was now far less "visible".
Many MSM, particularly of the younger generation, were found to
believe that they had not met anybody with HIV; it was therefore
difficult to strike the appropriate balance between stressing
the efficacy of treatment and highlighting the risk and impacts
of transmission. Throughout all prevention work, there was a need
to avoid stigmatising people with HIV.
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