Infiltrating the mainstream: the Queensland experience

HIV Australia | Vol. 10 No. 2 | October 2012

Chris Howard and Karen Porter discuss Positive Direction’s approach to service provision and the importance of engaging mainstream services

‘I needed some dental work done and decided to go to my local dentist, instead of the one 100km away from the small town I live in. I completed the form that asked me about medical conditions, including whether I was HIV-positive.

When I handed the form over I asked the receptionist what their policies for privacy and confidentiality were, with the added warning my form contained information that was very ‘private and confidential’.

The receptionist assured me such policies existed and were adhered to. I felt somewhat confident in the protection this afforded me. That the receptionist was also my neighbour however was not reassuring. It struck fear in me.’

In the current climate of fiscal conservatism, it is possible to foresee HIV-specific service delivery in Queensland impacted by reduced public health spending and retracted human and financial resources.

It is timely, therefore, to examine ‘mainstreaming’ HIV service delivery in light of the factors likely to influence successful mainstream service engagement, at different social-ecological levels of the health care system. An increase in referrals to mainstream services in Queensland may call for a new focus on ‘mainstreaming’ HIV.

Positive Directions, a program of Anglicare Southern Queensland, was formed in October 2004. At that time, Queensland was the only state in Australia that opted for such a model of care for individuals living with HIV and since then Positive Directions has remained the only organisation of its type in Australia.¹

Our model is a collaborative, coordinated and integrated approach to service provision, providing a suite of holistic supports including self-management education; referral to other services; and care coordination services.

The nature of the HIV epidemic is changing: people are living longer with HIV due to increasingly effective combination antiretroviral therapies.

As the epidemic evolves, so do the clinical and social support needs of people living with HIV. As a result, the focus of care for many has shifted to managing co-morbid conditions associated with long-term HIV infection, such as stroke, cardiovascular disease, kidney and liver diseases.²

The current model for the delivery of HIV treatment is based on accessing s100 prescribers for combination antiretroviral therapy: GPs in the community; HIV specialists; and doctors at sexual health clinics.³

While complicated clinical care is best provided by specialist and experienced HIV clinicians, traditional health care that builds largely on acute, episodic models of care is ill-equipped to meet the long-term and fluctuating needs ofthose with chronic conditions.

Positive Directions is tasked to develop care coordination responses to facilitate access to a range of services that are appropriate to the complex health and welfare needs of people living with HIV throughout Queensland.

For people living with HIV, stigma and discrimination and the fear of public exposure and vilification can undermine willingness to engagewith mainstream services.⁴

The protection that private and confidential HIV-specific services afford HIVpositive people is highly valued by those who are particularly fearful of and vulnerable to social alienation, including those living in regional, rural and remote communities.⁵

In recent years researchers have examined changes in the location of the HIV-positive population in Queensland, warning of the implications for service delivery anddevelopment.

Their findings suggest that while differences in service use appear to be related to geographic accessibility of different service types, there may be other important social, economic and cultural factors, such as ageing and socio-economic pressures involved.⁶

Chronic conditions require complex models of care, involving collaboration among practitioners, professions and institutions that have traditionally worked independently of each other.⁷ Positive Directions responded to this need through the development of an integrated, more coordinated approachto service delivery.

Positive Directions constructed a service model that aims to achieve continuity of care and better health and wellbeing outcomes for our clients. This approach seeks to ensure that support and education is delivered to the community and practitioners in a logical, connected and timely manner.

Self-management education focuses on the skills, knowledge, self-efficacy, motivation, resources and information required for an individual to selfdetermine and actively work towards and achieve health and wellbeing goals.⁸

This core component of our service delivery model works to provide people living with HIV information that will assist them to self-manage their chronic condition and adopt health and wellbeing enhancing behaviours.

To this end, we are skilling staff to deliver a range of Chronic Condition Care Models including the Health Change Australia’s Model of Change, the Stanford Model (HIV Adaption), and Brief Interventions for Chronic Conditions (an initiative of Anglicare Southern Qld) – complementary models suited to different service delivery and cultural contexts (i.e. individual/group; clinical/ psychosocial support).

Positive Directions has begun work to implement this self-management programming model across Queensland. Under the model, a Coordinated Activity Plan is developed in response to the identified needs of each individual, ensuring engagement is structured towards developing skills, knowledge, self-efficacy and motivation. The goal is to empower and prepare individuals to manage their health and health care.

On interpersonal and organisational levels, the interdisciplinary members of Positive Directions work to provide information to relevant mainstream agencies/service providers on HIV issues and service provision, ensuring such information will enhance sensitivity and understanding. In 2002, UNAIDS declared ‘mainstreaming’ an essential approach for expanding multi-sectoral responses to HIV/AIDS.⁹

Mainstreaming is not an end in itself, but a means to ensuring that HIV is central to all programmatic activities – policy development, research, advocacy, resource allocation, and planning, implementation and monitoring of programs and projects.¹⁰ The objective is to stimulate all entities within the health system to take HIV into account in program development and delivery.

Appropriate HIV mainstreaming is required in key Queensland sectors, particularly education, employment and aged care to engage more people, practitioners, program developers and policy makers. Mainstreaming requires appropriate human and financial resources and there must be commitment to developing partnerships among the various sectors.

In 2010, researchers from the Australian Research Centre in Sex, Health and Society, called for a balance to be struck between mainstreaming HIV service delivery and increasing the accessibility of HIV-specific services.¹¹ To achieve this balance, a proportion of service delivery must transfer to mainstream providers, and this successful transition requires an increased focus on ‘mainstreaming’HIV.

Mainstreaming cannot develop of its own accord. Systemic advocacy, widespread sensitisation and individual capacity building must occur in order to place people in a better position to undertake ‘mainstreaming’.

Mainstreaming highlights the importance of broadening and strengthening strategic collaborative partnerships between government sectors, community and health service providers and professional practitioners at all social ecological levels of thesystem.¹²

Mainstreaming efforts of Positive Directions will mean that mainstream services in Queensland are better positioned to respond to the needs of people ageing with HIV who may be experiencing chronic co-morbid conditions that require complex levels of care and support.

References

1 Lambert, S., Fitzgerald, L., Page, A. (2010). Final report of the Service review and evaluation of Positive Directions. University of Queensland School of Medicine and School of Population Health, Queensland.

2 Jansson, J., Wilson, D. (2012). Projected demographic profile of People Living with HIV in Australia: planning for an older generation. PLoS ONE 7(8):e38334. doi:10.1371/journal.pone.0038334

3 Carman, M., Grierson, J., Pitts, M., Hurley, M., Power, J. (2010). Trends in the location of the HIV-positive population in Australia: Implications for access to healthcare services and delivery. Sexual Health, 7, 154–158.

4 Fitzgerald, L., Scherman, J., Lambert, S. (2010). Final report of the project social Isolation for People Living with HIV/AIDS in South East Queensland: determinants and consequences. University of Queensland School of Medicine and School of Population Health, Queensland.

5 ibid.

6 Carman, M., et al., op. cit.

7 World Health Organization (WHO). (2002). Innovative Care for Chronic Conditions: building blocks for action. ISBN: 9241590173 Retrieved from: www.who.int

8 Victorian Department of Health. (2010). Incorporating self-management support into primary care. A fact sheet for Primary Care Partnerships [online]. Retrieved from www.health.vic.gov.au

9 JSA Consultants, GZT Regional AIDS Program. (2002). Mainstreaming HIV/AIDS: a conceptual framework and implementing principles. UNAIDS, GZT, Accra, Ghana. Retrieved from: www.afronets.org

10 ibid.

11 Carman, M., et al., op. cit.

12 The Social Ecological Perceptive is a theoretical framework that informs Positive Direction’s approach to service delivery. This theory considers the a range of influences society has on the individual at multiple levels. For further explanation see: Bronfenbrenner, U. (1979). The ecology of human development. Harvard University Press, Cambridge; see also Centres for Disease Control and Prevention (CDC). The Social-Ecological Model: A Framework for Prevention [online]. Retrieved from www.cdc.gov

Chris Howard is Northern and Central Qld Regional Coordinator at Positive Directions. Karen Porter is Systems and Quality Coordinator at Positive Directions.