Pender Community Health Centre

Success• Patient's engaged in care 85% in 2011 to

100% in 2012-13

• Lost to care patient reduced from 10 in 2011 to 0 in 2012-13

• Viral load testing q 4 mths from 82% 2011 to 98% in 2013

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Successful Changes• Establishing the HIV registry and

constantly upgrading it• Forging community contacts especially

outreach• Monthly case management of "gaps in

care" patients

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Innovation• Creating  a User Manual for registry

maintenance and sustainability.• Developing creative ways to help patients

transition from DTES clinic to various areas in BC .

• Developing Aboriginal resource list (eg initiation of monthly Talking/Healing Circles at Pender).

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Challenges• Decreasing active POF from 65 in 2001 to 54 in

2012 to 45 in 2013.• Overall uptake for ARVT remains at 78% and at

88% for those in greatest need.• Outside data presented at HIV Update in Nov 2012

suggest leading cause of death in HIV + persons is End-stage liver disease ( and 80-90% of our HIV+ population is co-infected) followed by addiction- overdose mortality .....

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Challenging Questions ??• How do we increase our availability and reduce

our barriers for HIV + patients in the DTES??• Recognizing that our patient population is often

transient ( in & out of jails, hospitals, recovery programs) and often striving to leave the DTES.  How do we try to improve these transitions?? How to avoid splitting patient care?

• How do we support our patient for earlier and sustainable initiation of ARVT??

Ideas for the future• Increase linkage with community teams to

identify and reduce barriers for access.• Consider broadening scope for more

outreach and treatment specifically directed at Hep C co-infected patients.

• Continue efforts to develop creative individualized ways to open the door for more HIV + patients and help them transition their care outside DTES.

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