Fraction of HIV Residents Getting Treatment in Downtown Eastside

Vancouver's Downtown Eastside has an estimated 1400 to 1900 residents who are HIV-positive, but only 316 currently receiving the recently developed anti-retroviral treatments that could dramatically extend their lives, The Tyee has learned.

These numbers were first revealed to The Tyee by a professional working at the BC Centre for Excellence in HIV/AIDS and confirmed by examination of provincial health statistics and conversations with several knowledgeable health care workers and researchers interviewed for this story.

While the Vancouver neighborhood's numbers on level of treatment compares favorably with dismal levels accomplished in the Third World, experts and observes told us in recent interviews that BC could and should be doing better at reaching and treating HIV-positive patients.

The population of the Downtown Eastside was estimated at 16,275 in 2003 when Vancouver had just over a half-million residents. Currently, about half the province's 3,233 patients on retroviral treatments for HIV/AIDs live in Vancouver.

"There is a real need to look at this neighborhood's marginalized populations," Dr. Thomas Kerr, a researcher with the BC Centre for Excellence in HIV/AIDS told The Tyee in a recent phone interview. Dr. Kerr said the numbers The Tyee had obtained for estimated HIV-positive residents and for the fraction of those residents receiving treatment seemed accurate to him.

"Clearly, there is a problem," said Dr. Kerr, who has done research and evaluation on the work of the neighborhood's pioneering supervised drug injection site. "Continuing to let things go on the way they are is unacceptable. From every perspective, human rights, medical and economic, we have to find ways to get more people into treatment. It's simply the right thing to do."

'Treatment levels too low'

Dr. Mark Tyndall, Epidemiology Program head for the Centre for Excellence also confirmed that the numbers on treatment The Tyee had obtained were roughly accurate.

"That's in the ballpark," Tyndall told The Tyee. "There is definitely a shortfall."

Paul Lewand, chairperson of BC's Persons with AIDS organization, like many experts and activists consulted by The Tyee, indicated the numbers we had obtained on levels of HIV treatment in the Downtown Eastside were both accurate and alarming.

"Treatment levels are too low," Lewand said in a phone interview. "There are so many causes and so few solutions that are not expensive and experimental."

Dr. Tim Christie, a staff ethicist with the BC Centre for Excellence in HIV/AIDS, is concerned about the low levels of treatment in the Downtown Eastside for these potentially life destroying conditions and would like to see the public health care system make more aggressive efforts to reach out to residents who could benefit from treatment.

"Currently," Christie said, "we'll treat anyone who comes to us, but only if they'll play by our rules. I'd like to see us putting a bus into that neighborhood every day that would distribute anti-retroviral drugs for HIV/AIDS and pay patients an incentive amount each time they take their medication. In terms of reducing suffering and death, we'd be on a stronger ethical footing if we were doing more outreach."

Christie's call for more robust outreach to potential AIDS patients in the Downtown Eastside makes sense in terms of what has worked so far. Most of the estimated 316 HIV positive patients in the neighborhood who are on treatment are enrolled in one of the three programs in the neighborhood that involve intensive, often daily, supportive contact between health care workers and patients.

The Maximally Assisted Therapy - or MATS program, at the Downtown Community Health Clinic, a multi-disciplinary team approach, involves daily attendance at the clinic by the approximately 85 patients currently enrolled, while high intensity programs operated by the Vancouver Native Health Society and the Pender Clinic serve approximately 180 more HIV-positive patients in the neighborhood, the Centre for Excellence's Tyndall told The Tyee.

Tyndall's response to the suggestion of a daily treatment bus in the neighborhood was supportive in principle, but pessimistic about its political viability.

"I have no issues with that idea," he said. "It would be cost effective, and we do know that incentives work, but I don't think taxpayers would be likely to support it."

Call for housing, resources

The low percentage of HIV-positive residents receiving treatment in the Downtown Eastside does not amount to "deliberate discrimination," Dr. Perry Kendall, BC's Medical Health Officer, told The Tyee in a telephone interview.

"BC is the only province to provide free anti-retroviral drugs on demand, and it's not that we're unaware of the problem," said Kendall. "But so many of these folks are hard to reach. People in treatment tend to be more organized and to have secure housing. Many of the folks in the Downtown Eastside don't have a regular primary care physician or other resources necessary for effective treatment."

Kendall said that across the province, one in three HIV-positive patients is being treated with anti-retroviral drugs. (For the Downtown Eastside, the figures obtained suggest a ratio closer to one in five or one in six.)

"All these problems," Kendall said, "are compounded by lack of housing. The Vancouver Coastal Health Authority is partnering with Vancouver city and other bodies to try to provide more secure social housing. If we had more money, we could do more. But we all work within budget constraints. It is a question of balancing finite budgets and many different demands. Although I agree the numbers of patients being treated with anti-retrovirals in the Downtown Eastside are low, it is important not to just focus on HIV and its treatment. What we need to see is a sustained investment in housing, access to primary care and job counseling as well as AIDS treatment."

Kendall was cautiously supportive of Tim Christie's suggestion for a treatment bus bringing medication and incentives to HIV-positive patients in the Downtown Eastside.

"That's a model that's been used with some success in other areas, like TB treatment, but you would have to have the sort of outreach team that was used with TB, going out and finding people everyday to make sure they are taking their medications."

Stigma an issue

Ann Livingston, a long-time advocate for injection drug users in the Downtown Eastside through the Vancouver Network of Drug Users, said, "We need to create neutral, non-stigmatizing programs where people can get services without outing themselves publicly as HIV-positive."

However, Livingston said that access to AIDS medication is not a big priority for her group.

"Why fight to push expensive drugs down people's throats when they are homeless or living in SROs (single room occupancy hotels)?" she asked. "The pharmaceutical companies are making big profits. They should leave us a legacy of social housing down here, not pissant little stipends on drug trials."

BC Persons with Aids spokesman Paul Lewand is more optimistic about what can be accomplished by attempts to get HIV-positive Downtown Eastside residents involved in supportive programs like the Maximally Assisted Therapy operation at the Downtown Community Health Clinic.

"We need more programs like MAT," he said. "They could save lives and money. Even if lifestyles remain the same, there is much less damage for people who are in treatment."

Vancouver journalist Tom Sandborn is a regular contributor to The Tyee.