An HIV / AIDS Prevention Outreach Program in Scarborough for People Who Inject Drugs

A proposal to the AIDS Bureau Ministry of Health, Province of Ontario
Author(s): 
Prepared for the Scarborough HIV / AIDS Network (SCHAN) by Raffi Balian & Walter Cavalieri
Program Location

Recommendation - The Host Agency
Recommendation - The Satellite Agencies
Benefits to Host / Satellite Agencies
Responsibilities of Host and Satellite Agencies
Host and Satellite Agency Orientation
The Relationship Between the Host and Satellite Agencies and The Outreach Worker

The Advisory Committee
Providing Direction for the Outreach Worker, Coordinating the Relationship Amongst Agencies, and Ensuring Liaison and Coordination With Other Outreach Services
Mechanism for Settling Disagreements
Protocols

Hiring Committee

Future Directions

Appendix A
Job Description: AIDS Prevention / Harm Reduction Community Outreach Worker

Appendix B
Budget

Appendix C
The Role of the Scarborough HIV / AIDS Network (SCHAN)

Appendix D
The Role of Public Health

Appendix E
Recommendations to the AIDS Bureau

PREFACE:

THE PROBLEM

At the Canadian Association of HIV/AIDS Research Conference held in Ottawa in May, 1997, results from studies in Vancouver and Montréal indicated a dramatic increase in HIV infection in the injection drug using communities. Although, to date, the rate of infection is not so high in Ontario, the AIDS Bureau of the Ontario Ministry of Health recognized the potential for a serious elevation in the infection rate in injection drug users and has been working toward finding practical interventions to prevent this from happening.

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TAKING STEPS TOWARD ADDRESSING THE PROBLEM:

THE OUTREACH WORKER PROGRAM

In September 1997, the AIDS Bureau held a consultation meeting with community representatives to discuss ways to reach people who inject drugs, in order to deter the spread of HIV. One of the results of this meeting was the Bureau's decision to provide funding for15 Outreach Workers who would be strategically placed around the province, working with community partners to complement existing services.

Using data from current research as well as estimates of the number of drug users in areas of the Province in relation to their population, certain locations were identified as needing additional resources and strategic interventions. These locations included Ottawa, which will have two Workers, the newly expanded City of Toronto, which will have six Workers and seven other areas in the Province which will have one Worker each.

The AIDS Bureau specified that funding for these Outreach Workers will be allocated to agencies with a demonstrated history of leadership and expertise in HIV / AIDS and will serve to support the existing infrastructure in being a value-added initiative. The proposal put forward in this document addresses the duties and location of one of the Outreach Workers in the former City of Scarborough, as well as the timing and process of phasing in the service.

PROGRAM GOAL

The goal of the Program is to stop or to significantly reduce the spread of HIV among people who inject drugs, their families and their community.

CRITERIA FOR THE DEVELOPMENT OF THE PROGRAM PROPOSAL

  • The AIDS Bureau developed a list of criteria for the development of the proposal. The Bureau specified that the programme should:
  • Be developed locally, in consultation with existing services which serve the community of concern;
  • Include a Peer component;
  • Complement - not duplicate - existing services;
  • Access the HIV Program at the Addiction Research Foundation for training;
  • Define and demonstrate mechanisms for the involvement of other community services;
  • Assist in reaching those not presently accessing services;
  • Develop staffing and hours of service which accommodate the needs of the community;
  • Work toward reducing the isolation of members of the community of concern;
  • Include a comprehensive orientation plan for the Workers;
  • Include a mechanism for supporting the Outreach Workers;
  • Include an evaluation component.


THE PROGRAM DEVELOPMENT PROCESS

The Scarborough HIV / AIDS Network (SCHAN) was approached by the AIDS Bureau to determine the shape of this AIDS Prevention initiative in Scarborough. SCHAN is composed of people concerned with preventing the spread of HIV / AIDS in people who use drugs, their families and their communities. Some of its members are drawn from agencies and businesses in Scarborough, others from AIDS service organisations in Toronto.

A subcommittee of SCHAN drew up program criteria and issued a call for submissions, requesting that putative consultants address such issues as:

Objectives;

  • Activities (including strategies for outreach, stakeholders to be consulted and why);
  • Process / means by which information will be gathered;
  • Time lines;
  • Evaluation.

 

A team of consultants was hired and given approximately five weeks to prepare recommendations.
The consultants undertook an environmental scan to determine where the services of Outreach Workers would be most valuable in Scarborough, who needed services, and what the services were to be like. To gather the necessary data, they framed five questions which they felt needed to be addressed:

What is your drug of choice / method of use?

What services and supports do you need as a person who uses drugs?

What services are you accessing in Scarborough, and how do they treat you?

If there were one place in Scarborough where services specific to your needs should be provided, which agency should it be . . . or where should it
be?


Questions were also prepared for agencies which were considered as possible home bases for the Outreach Worker and Peer Support Worker. These included:

Tell us about the people you are seeing in your agency who are using drugs. E. g., age, race, drugs of choice.

What special problems do they present with?

What services do you provide to them?
E. g., direct client support / services
distribution of materials / supplies
individual counselling
individual education / support
information
education
peer / volunteer program

How would you describe your service philosophy in regards to working with people who are using drugs.

What is your experience in working in the area of AIDS prevention / education treatment / support?

Do you see the need in your agency for more services to this population?
What services?


Would you be willing to provide more services?
What services?
(Check regarding needle distribution / exchange, an Outreach Worker, Peer Support Workers, drop-in, etc.)

In what ways might an AIDS Prevention / Harm Reduction Outreach Worker enhance / complement the work which your agency is already doing?

 

Approximately sixteen potential service users were interviewed, in groups and individually, both in the community and in jail. Staff members of six agencies were also interviewed.

Simultaneously, police in Scarborough were interviewed regarding "hot spots." This information was supplemented by data from Toronto police, as well as from people in Toronto who deal and use drugs in Scarborough. The consultants spent a considerable amount of time visiting the locales which had been identified by the police and through their own research.

The consultants also called upon their knowledge of the drug scenes and their personal experience in program development and service delivery to address the particular issues which exist in Scarborough.

Information was shared with a subcommittee of SCHAN as it was gathered, and ideas about service delivery were vetted with them as they developed.

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FINDINGS AND OBSERVATIONS:

DESCRIPTION OF SCARBOROUGH

Canada's seventh largest city, Scarborough was, until very recently, a suburb of Toronto. As such, one of its primary functions was to provide homes for more than five hundred thousand people who, a large number of whom worked and played in Toronto. Many new Canadians have settled in this region. Because of this, the re is a rich range of racial, ethnic and cultural communities, which represents the reality of the recent patterns of Canadian immigration. Some of the ethnic populations have integrated, but many stay close to their own communities, even after a generation or more.

Similarly there is a revealed range of class and status, extending from old, stable neighbourhoods to areas where supportive housing, poverty and transiency are over represented. Here, as elsewhere, it is difficult to transgress the barriers of race and class, and it has become more difficult as the economic trend has been toward a greater disparity between rich and poor.

Like many "suburbs", Scarborough does not appear to have a real centre, a natural hub of life and activity, including illicit activity. In the case of drug use and distribution, it occurs all over the map! Moreover, it has become increasingly visible to police and agency staff. As well, it has become problematic (and a target) for members of the general community where it has become visible - for example when combined with street prostitution.

Where they are concentrated, various ethno-racial communities have spawned businesses and supportive community organizations. Members of these communities, therefore, can access goods and services which satisfy some of their cultural and spiritual needs, as well as some of their health needs. However, such is the stigma that, when it comes to services for people who use illicit drugs, there is an almost complete dearth of services or support. There is no needle exchange program, no detoxification centre, no opiate addiction treatment clinic, no drug treatment program supported through OHIP (and only a small handful of physicians licensed to prescribe methadone, who are by and large unknown to a majority of users), no adult hostel, no focussed outreach to people who use drugs, and minimal application of harm reduction as a service philosophy. One gets the feeling that, in Scarborough, no one is abusing drugs, and no one is homeless. Our interviews and observations indicate that this is not the case. Similar comments may be made in the case of care and support for people with HIV / AIDS.

Obviously, people who use drugs are not obtaining the services they need in their own back yard, but are compelled to go to downtown Toronto or, occasionally, to Oshawa.

People - agency personnel and users alike - raised concern that there is little political or "community" will to bring about effective HIV / AIDS prevention outreach to people who use drugs, especially those who inject. The doctrinaire "Just Say No!" approach is easier to understand, easier to accept and, frankly, easier to work with than a subtle client-centred harm reduction approach, although the former has proven to be ultimately ineffective, costly and futile in the long run for the majority of people. In other words, it seems that Scarborough has failed to catch up with other large Canadian cities regarding contemporary drug treatment / prevention approaches.

With the incorporation of Scarborough into the so-called "megacity" of Toronto, it is hoped that the arbitrary barrier of Victoria Park Avenue will disappear, allowing for the "levelling up" of the services of public health and the extension of its accessible, mobile harm reduction services to Scarborough residents who use drugs and /or work in the sex trades. Until then, to the degree which it is possible, this work must be catalysed and carried out essentially by the Outreach Worker, Peer Support Worker(s) and Volunteers described in this proposal, with the cooperation of agencies who have concerns about and obligations toward the designated population.


THE "SCENE"

Users and dealers alike have identified that most of the action is "invisible" to the untutored eye. It takes place in low-rent high rises (particularly subsidized housing projects), doughnut shops and bars. Unlike in downtown Toronto, there is little street activity and no hub or core. The lack of a hub is crucial in determining what kind of services will be delivered and, even more, how they will be delivered. That notwithstanding, it is clear that the Kingston Road area, particularly from St. Clair to Highway 401, with its obvious street prostitution, has become a neighbourhood concern largely because of the visibility of the working women.

Regarding the drugs of choice in Scarborough, cocaine (in the form of crack) is generally preferred. However, that is not to minimize the amount of heroin being consumed, especially by Asian and white drug users. Crack is being smoked more frequently than it is being injected, but that use pattern appears to be changing.

Our informants have also indicated that powdered cocaine is "moving up" from the predominantly white drug-user areas (Danforth and Victoria Park), to historically crack-using neighbourhoods, particularly the Kingston Road / Galloway region. Powdered cocaine is no longer the exclusive domain of the middle- and upper-class user.

This trend must be seen as a lode star for a fundamental change in service provision, since the injection of cocaine demands a ready supply of a large number of new needles, an imperative if there is a real commitment to slaking the spread of HIV and Hepatitis C. Compound this with the relationship between poverty and chaotic drug use . . . between poverty and illness . . . between class and /or status and barriers to and denial of health care services . . . and the likelihood of a costly and life threatening health crisis and a radical change in service provision becomes apparent. HIV / AIDS is merely one of several critical health issues rampant in the communities of concern, and it cannot be effectively addressed discretely. The extensive and deleterious sequelae of poverty, bigotry and marginalisation must also be dealt with.

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THE OUTREACH PROGRAM:

A LOCAL SOLUTION

In a community as spread out and decentralised as Scarborough, the only practical system is one which depends on good telecommunication and ease of transportation. Outreach must be flexible, quick, imaginative and responsive to the call of community members. The rapid provision of prevention materials is underscored by the fact that cocaine (generally in the form of crack) is the drug of choice in Scarborough.

One of the critical issues which the consultants addressed was the definition of outreach in the context of the Scarborough reality. The simplest definition of outreach limits it to "street outreach" - that is to the activities of Workers (usually two - and never less) who do their work detached from an "office", on foot or on or in a vehicle, providing services in the locations where the population of interest congregates or works. It is all of this . . . and much more.

In Scarborough, outreach includes such activities as rapid delivery of necessary supplies; the development of user- and agency-based secondary distribution strategies; displays and education on site - in bars and other places where prospective service users hang out; extensive agency liaison; education of the personnel of partner agencies; program promotion; community identification, development, mobilisation and advocacy; escorting clients to appointments; supporting clients at court; informing and mobilizing agencies, communities, media; etc. The work of the "Outreach Worker" is both individual and systemic, and just exactly how that is played out will depend on the total neighbourhood environment and the needs of the community of concern as they unfold.

Until Toronto Public Health "levels up" its services in Scarborough and provides fixed and mobile HIV / AIDS prevention services for people who inject drugs (if indeed this does occur), the program proposed here will be the only game in town. Even after Public Health "levels up", this program will offer services in a more "front line", "grass roots" manner. Considering the geography of Scarborough and the needs of its residents, this program faces a daunting task. Its success will depend on the commitment of SCHAN, on the development of a network of partners and a strong volunteer component (fortunately both of these latter two approaches - networking and the use of volunteers - have strong historical roots in Scarborough), and incremental growth in funding and staff.

As we visualize it, the program - when it is in full operation - will appear as a web superimposed over Scarborough. The web will emanate from a central site, the Host Agency, which will serve the base of operations for the Outreach Worker and the Peer Support Worker(s). The program will be anchored at a number of secondary or Satellite Sites located at accessible agencies. Each of these locations will contain a small harm reduction program, staffed and / or supervised by the Outreach Worker, assisted by one or more trained staff from the agency itself. In the first year two Satellite Sites will be opened. In subsequent years, additional Satellite Sites must be opened to achieve effective coverage of the entirety of Scarborough.

Vehicular and telephone communications comprise the threads of this web. The Outreach Worker must have a car for the delivery of HIV / AIDS prevention information and harm reduction supplies as well as for travel between sites, and a generous budget for car expenses and TTC tickets. The Outreach Worker must also have a cell phone and so that she / he can have immediate access to the home base, clients, volunteers, and ambulance and police, for safety reasons. Often the work is performed in dark, isolated streets, where safety is a concern, or where there are no public phones, or public phones are located in unlit areas. Each site should ideally have a computer and be connected to the Internet, not merely for the convenience of E-mail, but also for access to up-to-date information from myriad international sources. Finally, key program staff will require pagers.


CLIENT-CENTRED SERVICE - HARM REDUCTION

In progressive jurisdictions around the world, the principles of harm reduction are recognized as offering the most efficacious guidance in dealing with drug-related problems, both individually and in respect to community.

Harm reduction is not so much a set of practices as it is the ethical, philosophical and practical underpinning of a way of providing service to people and communities who use / misuse drugs. While the explicit goal of harm reduction is to mitigate the harms to individuals, families and society which might result from drug use and drug distribution, implicit are a number of overarching principles:

that the community has a collective responsibility for the well?being of all its members, and that individual members have a responsibility for the well?being of the community;

that all people are of equal and intrinsic worth and are entitled to equal treatment;

that all people enjoy the right of self determination and the right to live with dignity;

that all people have a basic right to participate actively and directly in the formulation of decisions and policies that effect their lives.


Putting a harm reduction approach into practice means that you provide people with the full range of health and social services without requiring them to stop using drugs as the ticket for admission to - or receipt of - these services.

It means, as well, that the level of availability and quality of service and treatment that people who use drugs receive will be no less than that provided to others who may not be using drugs.

It means that services will be offered without discrimination, prejudice or negative judgment, and that the quality of those services will not be compromised because of discrimination, prejudice or negative judgment.

It requires that one accept that a person has the right to use a substance to get relief or for pleasure.

It acknowledges, for example through the use of re-framing, the successful accomplishment of the person's choice of behaviour and works respectfully and collaboratively with her to reduce the harm or possibility of harm which might ensue from the exercise of that choice.

It is definitely not a top?down approach. In fact, it acknowledges and respects the expertise of the service user.

Succinctly stated, a harm reduction approach answers to the principles of public health and social justice.


A SCOPE OF PROGRAMMATIC RESPONSES

It is essential for the successful realisation of the goal of this Program that all services are delivered from a harm reduction perspective. With this in mind, the following objectives and activities are recommended.

To provide HIV / AIDS prevention information materials, education and support at the Host Agency and to ensure that they are offered at the Satellite Agencies and other sites:
Access the HIV / AIDS program at the Addiction Research Foundation for training.

Provide AIDS Prevention / Harm Reduction / Health Promotion outreach and services to members of the community of concern, where they work and where they live.

Develop HIV / AIDS and harm reduction materials as needed.

Provide good referrals and support community members in carrying through on the referrals.

Accompany community members to services / appointments as necessary.

Provide general counselling and support to community members.

Broker and advocate for services for their constituents, individually and systemically.

Encourage and facilitate use of services of the Host Agency and in the community.

To ensure that there is a presence in the community, when and where it is needed.

Provide on-call services for users, e.g., delivery of harm reduction services and materials, informal counselling, etc.

Provide direct services "after hours" and on weekends and holidays, through such means as split shifts, the judicious use of volunteers, limited morning hours, etc.

Provide outreach, education and harm reduction services, and promote the philosophy and services of the program, where potential service users congregate, e.g., shelters, bars, doughnut shops, malls, etc.

Provide outreach regarding safer intramuscular injection of steroids to youth in gyms and students at risk of dropping out of school enrolled in special alternative high schools programs.

To develop networks among agencies which are rendering services - and those which might render services - to members of the community of concern, through the provision of education and consultation.

Provide staff development and individual client and program consultation regarding the health and social issues affecting the community of concern, how they bear upon the health of constituents and how to address them individually or from a community perspective.

Identify satellite agencies and assist them in developing appropriate community-based programs in response to community issues, such as drop-ins which provide safety and hospitality; educational, leisure activity, wellness or support groups; a newsletter; etc.

Identify and liaise with existing harm reduction services and workers, in Scarborough as well as in the city of Toronto, in order to develop and provide coordinated and effective means of client finding and service delivery.

Develop partnerships with other agencies doing this work and / or whose services are or need to become accessible to community members, e.g., hospitals, community centres, health centres, etc.

To provide the opportunity for Peer employment and the use of Volunteers.

Develop a mechanism to provide employment for community members and volunteers (Peers) to assist in the delivery of services.

Identify potential Peer Support Workers and Volunteers and participate in interviewing and selecting them.

Facilitate the provision of training in HIV / AIDS prevention, boundary maintenance, basic listening skills, etc., for Peer Support Workers and Volunteers.

Provide Peer Support Worker(s) and Volunteers with programmatic supervision.

Develop, foster and provide the mechanism for engaging Peers and Volunteers in the secondary distribution of harm reduction supplies and material as needed.

To promote the awareness of the program among the community of concern.

Make use of such means as handbills, stickers, posters, ethnic / community newspapers, radio and TV, TTC advertising, etc., to inform people of the Program and its services, safer drug use, etc.

To provide outreach and education in the East Detention Centre, as well as to incarcerated Scarborough drug users.

Provide HIV / AIDS prevention outreach education.

Develop and maintain liaisons with community members in jails / prisons to provide transitional support when they return to the general society.

Advocate for methadone maintenance and ensure the continuous and timely provision of HIV / AIDS medication.

To maintain statistical data regarding this program.

To participate in program evaluation in conjunction with SCHAN.


RELATIONSHIP WITH THE POLICE

The success or failure of any program that deals with illegal activities is contingent on developing sound relationships with the local police. Negotiations must not be left to the Outreach Worker or the last minute. They will be credible and effective only under certain conditions.

The negotiators have to be good "outstanding" citizens, e.g., the Medical Officer of Health, executive directors of key community agencies, etc.

Negotiations have to take place from the point of view of public health and police safety rather than the rights and safety of the drug user, no matter how important that may be.

Negotiations must be ongoing, with the parallel support and provision of training and education of members of the Police Force.

If police are intransigent and unwilling to support the work of the Outreach Program, then the Medical Officer of Health should consider enlisting the help of the Ministry of Health, under whose auspices this program is operating.


THE PHASING-IN PROCESS

The First Year

Although, ultimately, the majority of work will be done outside the office at the Host Agency, during the initial period, the Outreach Worker must initially dedicate time to setting up the space, acquiring materials, developing liaisons with and relationships with other agencies and agents and particularly building her / his credibility with people in the community of concern.

The following are suggested time lines. They are not rigid. The importance is that the Outreach Worker carry out the job in a thorough and timely manner, respectful of community needs and the limitations of reality.

During months one through three . . .

Familiarise her/ himself with the Host Agency

Develop a plan for harm reduction training for the Host Agency and potential Satellite Agencies

Develop an implementation plan for service delivery

Initiate harm reduction services on site, with regular hours convenient for service users

Provide information / education and support to service users

Provide supplies to service users, as required

Liaise / develop working relationship with the two future Satellite Agencies

Liaise with service providers to whom she / he will refer

Liaise with service providers with whom she / he may form partnerships

Liaise with harm reduction / needle exchange service providers throughout
Toronto

Undertake outreach to shelters, bars, doughnut shops, malls, etc., in selected parts of the city of Scarborough, in order to build relationships with people who are using drugs, promote and provide harm reduction services and enhance community

Identify pharmacies who will and will not serve injection drug users and develop and publish a list

Undertake outreach to staff and residents in housing developments in selected neighbourhoods, as necessary, in order to develop liaisons with people who are using drugs, promote and provide harm reduction services, develop links to Host and future Satellite Agencies and enhance community

Assemble and develop material on HIV / AIDS prevention specific to Scarborough and the services of the Outreach Program

Negotiate with local police (in conjunction with SCHAN)

To give Outreach and Peer Workers leave to work without harassment or surveillance

To give citizens leave to access services of this program without harassment or surveillance

To honour "Outreach ID Cards" carried by clients, and not confiscate new harm reduction supplies or make use of used harm reduction supplies as evidence for prosecution.

Develop a campaign to advertise range and confidentiality of the free and "user-friendly" services of this program, using community and ethnic media, local TV, TTC, etc.

Identify / solicit candidates for position of Peer Support Worker(s) and Volunteers

Select and arrange for training of Peer Support Worker and Volunteers

Develop "on call" harm reduction service services

Identify indigenous community leaders and, with them, start to develop and initiate secondary distribution of harm reduction supplies at volunteer satellite sites


During months four through six . . .

Oversee the opening of a harm reduction site at a Satellite Agency

Develop a coordinated schedule of operating times, convenient to a user

Participate in providing service to members of community

Maintain a harm reduction program at both Agencies (Host and Satellite), with regular hours

Provide information / education and support

Provide supplies as required

Train Host and Satellite Agency staff to assist in providing harm reduction services on site

Train Volunteers working in volunteer satellite sites

Maintain liaison with harm reduction service providers throughout Toronto

Phase in weekend and holiday hours

Phase in liaison with service users in jail / prison, as required

Monitor effectiveness of referrals

Follow through with service providers to troubleshoot and maintain quality

Maintain liaison with service providers with whom she / he may form partnerships, in order to enhance the referral network

Log unmet needs and advocate for service expansion as necessary

Continue to do outreach in hostels, bars, doughnut shops, malls, etc., in selected parts of the city of Scarborough

Continue to do outreach to residents in housing developments in these selected neighbourhoods, as necessary

Initiate campaign to advertise range and confidentiality of the free and "user-friendly" services of this program, using community and ethnic media, local TV, TTC, etc.

Work with Peer Support Worker(s) to increase community validity, awareness and use of the services of the program

Expand "on call" harm reduction services, as required

Continue to identify, select and train Volunteers for this program

Work with indigenous community leaders to maintain, enhance and expand secondary distribution of harm reduction supplies at volunteer satellite sites


During months seven through nine . . .

Oversee the opening of a harm reduction site at the second Satellite Agency

Develop a coordinated schedule of operating times for all three Agencies, convenient to users

Initiate liaisons with gyms and special alternative programs for "at risk"students in high schools, regarding steroid use

Participate in providing service to members of community

Enrich liaison and collaboration with harm reduction / needle exchange service providers in the greater Toronto

Expand campaign to advertise range and confidentiality of the free and "user-friendly" services of this program, using community and ethnic media, local TV, TTC, etc.

Maintain existing services

Assist SCHAN in the identification of funding sources

Advise on the preparation of grant applications


During months nine through twelve . . .

Maintain the operation of the program at the Host Agency and two Satellite Agencies; service on call; secondary distribution; jail liaison; etc.

Prepare for and undertake program evaluation

Participate in visioning and the preparation of short- and long-term program goals


HOURS OF OPERATION

People who use drugs want and would make use of 'round-the-clock services, seven days a week and definitely on weekends and holidays. This is their drug-use pattern. Because of this, when the Program is up and running, outreach will be provided seven days per week (though not 'round the clock), through mobile and fixed site services.

The following schedule is a recommended schedule:

A harm reduction service site will be open at the Host Agency at scheduled times during normal business hours. Selected agency staff will be trained to provide appropriate harm reduction services and resources and work with the Outreach Worker to offer service users different options, including referrals to needed services.

Unless special arrangements are made, the Outreach Worker, however, will work at the Host Agency site only during afternoon hours, Wednesday through Sunday. Even during these hours, the Worker will be on call to provide mobile service after 2:00 p.m.

The mobile service will be operational five days per week, Wednesday through Sunday, between 2:00 p.m. and 12:00 midnight (pager service only between 10:00 p.m. and midnight). Between Wednesday and Friday, the Outreach Worker must be at the office at 2:00 p.m. to confer with her / his colleagues at the host agency and to conduct administrative tasks.


TEAM APPROACH TO OUTREACH

The presence of two people from the pool of trained Workers (Staff, Peer or Volunteer or staff from a partnering agency) is required in all instances of off-site outreach, for reasons of safety and accountability and in order to maintain the integrity of the service.

MOBILITY / COMMUNICATIONS

Because of the size of Scarborough, and the fact that drug use in not centralised but occurs "across the map", the Outreach Worker must have a car, a pager and a cell phone. The car is needed to perform duties in a timely manner. A pager is a necessity as the means for connecting with the drug user without getting involved in unnecessary conversation and without giving up control of communication. The Worker needs a cell phone for safety reasons. It enables the Worker to call for backup and support in case of emergencies.

One of the most important requirements of this program is that the Outreach Worker delivers supplies as soon as paged. Immediate response to paging is not to be underrated, especially in a community where cocaine use is endemic. Cocaine users are driven; their use of the drug is compulsive. If users do not receive their harm reduction supplies within a reasonable amount of time, they will share equipment, putting them selves and the community at risk. Therefore, once the pager goes off, the Outreach Worker must immediately set out to deliver the supplies. Prompt service is an excellent outreach tool. Many drug users do not utilize programs because they are concerned that it will take too long to receive supplies. Once the word is out that service is speedy, drug users will be more prone to use the program.

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STAFFING ISSUES:

WORKER QUALITIES

The unique nature of Outreach Work among drug users must be acknowledged. The illegal status of drugs prevents many drug users from accessing the healthcare system. It is, therefore, of utmost importance for Outreach Workers to move beyond conventional dichotomous thinking and recognize the special circumstances of the drug scene and its participants. They must be aware of the genuine barriers to healthcare which are in place for this population, who put the barriers in place, the users' experience of the barriers, and the difficulty users have in removing or circumventing them.

Workers' insensitivity to barriers and their consequences constructs an additional barrier between them and the users. It is for these reasons that the issues addressed in this section, and the following one, must be thoroughly discussed with Outreach and Peer Support Worker(s) as part of the hiring interview and in their training and orientation.

People who use drugs are connoisseurs of service, both good and bad, and in situations of trust they will share their knowledge and experience openly. They are clear that they wish to receive services which are confidential from people whom they recognize as experienced and credible about drug use and drug-use risks, HIV / AIDS, health issues, including sexual health issues, and about services and service personnel at various agencies. What they are not always certain about is that they deserve to receive the kind of high-quality service they describe.

Equally important to members of the community of concern is the expectation that the Workers not judge or scorn them for what they are doing to survive, but treat them with respect and compassion. The concept of showing compassion for one's clients - of responding "from the heart as well as the head", of embodying one's humanity - is recognized and accepted in numerous contemporary therapeutic schemata, including self-relations and narrative therapy, where it is seen as a skill and a force that can heal, invigorate, reconnect, calm and encourage. It is also a cornerstone of harm reduction.

Service users also identify that Outreach Workers should be accepting of differences; without bias regarding race, gender, culture or age; accessible; politically committed; willing to take risks and go the extra mile for people; trustworthy; honest; good listeners; skilled at counselling; etc.

Workers armed with these skills and attitudes are capable of providing excellent support and information, as well as appropriate referrals and linkages . . . of "making a difference."

Outreach work is a high-stress occupation. Workers observe situations which are emotionally taxing, with one crisis after another. They have to have mental fortitude and good strategies for dealing with stresses and discouragement.

The work itself must be delivered from a harm reduction perspective, as stated in this document - that is, with total commitment to the belief that the use of drugs does not be viewed as a barrier to services, and that the person seeking service is the decision maker.

In Toronto interviews, respondents from the service user pool expressed concern that the Outreach Workers might be exploited: that they might not be paid sufficiently, might not be respected by managements for their perspective and expertise. Many people interviewed saw Peers as a valuable, necessary part of the service delivery system; however several also expressed concerns about the exploitation of Peers - educating them indifferently, not giving them much support, using them briefly and then dropping them.


WORKER VULNERABILITY AND SUPPORT ISSUES

To protect their integrity and the integrity of the Program, Outreach Workers must not conduct outreach on their own. It places them at too great a risk. Workers on outreach need the support of colleagues to protect each other from their own vulnerabilities.

Drug misuse among workers in a milieu of drug use is an ongoing concern, particularly those in direct and constant contact with injection drug users. There are many good reasons for this:

Outreach workers are constantly in the presence of drugs and have constant access to drugs.

Service users feel indebted to service providers. Many offer free drugs or sex as sincere tokens of their gratitude.

In some instances, drug users inject in front of outreach workers; after a while, injecting becomes demystified, and an important barrier is removed.

The unrelenting oppression of injection drug users has a profound effect on outreach workers. Often workers find themselves fighting an unequal battle. After a while, they develop righteous hostility toward the system and start identifying with their service users (subculture solidarity).

Subculture solidarity can isolate the outreach worker from conventional agencies. This is particularly true in an environment where agencies operate from an abstinence philosophy. When such agencies imply that the worker is "condoning" drug use, or oppose much of the worker's effort (for example, advocating to set up methadone programs), the worker feels alienated and turns to service users for validation.

Attempting to better identify with their service users, workers sometimes go to absurd lengths to share their reality.

Outreach workers are often isolated from the majority of agency staff and are not made to feel part of the agency as a whole.

Outreach workers are frequently accountable to several bosses, sometimes with conflicting philosophies. Their concerns are sometimes not given priority they feel they deserve, and their initiatives are often neglected or undervalued. The worker is disempowered and set apart from decision making processes.

In that they are isolated from abstinence-based addiction and treatment agencies (historically these are the agencies with power and money), harm reduction workers are often deprived of funding for the development of meaningful programs, as well as opportunities for professional development. They may become embittered by this.

The process of isolation, disenchantment, injection demystification, subculture solidarity, compounded by abundance of drugs, compounded by the abiding presence of despair, contributes to the temptation to engage in drug use.

If drug use is initiated, anti-drug attitudes in the workplace, not to mention embarrassment, may impel outreach workers to conceal it. The associated stress, coupled with the lack of access to confidential and prompt treatment, set the stage for drug misuse.

Outreach workers must be prepared to deal with the stressors and temptations associated with this type of the job and must be provided with the necessary supports. Otherwise, they will become vulnerable to violating boundaries at the expense of their own health, the health of their clients, and the health of the organization they work for. All workers should have extensive training to bolster them against boundary violations. As first-impact workers, they should also be familiar with all the appropriate resources in Scarborough and elsewhere.


ORIENTATION AND TRAINING: OUTREACH WORKER


The Outreach Worker must be provided with orientation, as needed, in harm reduction practices and outreach skills, prison issues, HIV / AIDS Prevention, and boundary maintenance (particularly regarding drug use and sex) from the HIV program at the Addictions Research Foundation, in partnership with appropriate community agencies, or from someone whom it recommends. The Outreach Worker will familiarize her- / himself with the agencies, programs and services in the community as well as with front-line harm reduction services in Toronto.

It is strongly recommended that Workers also receive training in first aid, basic health issues of people who use drugs and how to address them on the street, emergency overdose treatment, vein care and injection technique, etc., and be able to provide anonymous HIV testing (or have swift access to it). In a crucial position such as that of the Outreach Worker, the new employee must have, upon hiring, a high level of knowledge, skill and practical experience working with the populations of concern.

It is extremely important that the Outreach Worker receive a thorough orientation to the Host and Satellite Agencies and that they are integrated into the Host Agency as much as possible.

It is recommended that the Outreach Worker have access to this document.


ROLE AND SIGNIFICANCE OF PEERS

Compared to Vancouver, Montréal and Ottawa, Toronto - historically a cocaine using city - has thus far maintained relatively low rates of HIV infection. In our opinion, one of the reasons for low HIV rates among drug users is the practice of some Toronto Outreach Programs to use Peer Support Workers in all aspects of their strategies. The F.U.N. (Finally Understanding Narcotics) Group running out of the Parkdale Community Health Centre, the Ambassador Program and the Methadone Program at The Works, and the HIV / AIDS Prevention and Harm Reduction Program, running out of the Queen West Community Health Centre are prime examples . In contrast, other harm reduction based programs in Toronto, which do not employ Peer Support Workers or do not have any provisions for the inclusion of peer input, perform very poorly in terms of HIV / AIDS prevention among drug users. These programs have very limited contact with drug users and do minimal distribution (if any)of harm reduction materials, in spite of a high concentration of injection drug users in their areas.

There are many good reasons why the employees of agencies such as Black CAP (Black Community AIDS Project) are Black, and that the outreach workers with G-Men are Gay men. For years, research, common sense and front-line experience have shown that peer education works best and that peers should be included in every aspect of design, implementation, delivery and evaluation of all projects and initiatives. Yet, year after year, project after project, lip service is paid to this truism, and peers' knowledge and expertise are not adequately exploited. What is exploited is their time and energy.

The role of peer workers is even more important when developing a new outreach program in an area where drug users have not been historically contacted by the healthcare establishment. Peer Workers will greatly speed up identifying drug users and advocating for the credibility of the new Outreach Program. Their relationship with the Outreach Worker will convince users of safety and confidentiality of the Program, as well as offer them hope that one day they also could land a similar job. Finally, Peer Workers will greatly enhance the safety and accountability of the program.

SPECIAL CONSIDERATIONS: PEER SUPPORT WORKERS

Peer Support Workers should be members of the community of concern who have credibility and respect within that community, are committed to working for positive change, support the principles of harm reduction and possess the requisite personal skills to carry out the job.

Peer Support Workers must be given clear, written descriptions of what is expected of them and provided with a code of conduct which respects simultaneously their position as a member of the community of concern (and the reasons why they have been selected as Peer Support Workers) and their responsibility to do the job which they have agreed to do.

The issue of Peers' using or not using drugs is one which continues to come up. Peers are Peers because they are (or have been) using drugs. Their work as Peer Support Workers should not be contingent on their abstaining from the use of drugs. On the other hand, they also have a job to do. The expectation is that they will report for work capable of doing their contracted job and carry out their job in an effective and responsible manner.

It is worth noting that exposure to drugs may trigger, in a Peer Worker, increased or chaotic use of drugs. It is the obligation of the Host and Satellite agencies and the Advisory Committee to be helpful and supportive of Peer Workers in dealing with their drug use.

Peers deserve, and may need, ongoing support, monitoring and guidance at a higher level of intensity than do trained workers. Becoming a Peer Support Worker may enhance their vulnerability, destabilize their lives, distance them from some of their community supports, frustrate them. On the other hand, becoming a Peer Support Worker can be - and often is - an experience which opens them up to an appreciation of their value and efficacy and a revised vision of their future.

It is recommended that the Peer Support Worker have access to this document.


ORIENTATION AND TRAINING: PEER SUPPORT WORKERS

Peer Support Workers must have access to the same level of training as the Outreach Worker, including a thorough Agency orientation. As representatives of the Host and / or Satellite Agencies, and as co-participants in the delivery of harm reduction services, they cannot expect less. Peer Support Workers should also receive training in basic listening / attending skills. A micro-skills approach, because it is lucid, structured, succinct and effective, is a possible modality. It is very important that the training of Peer Support Workers addresses boundary issues.


ORIENTATION AND TRAINING: VOLUNTEERS

Volunteers who are distributing harm reduction materials and supplies should be trained and educated regarding the nature of these supplies, health and safety issues, how to develop and maintain nonjudgmental relationships, basic crisis intervention and management, conflict de-escalation, confidentiality, rules and regulations of the Host or Satellite Agency, etc., to the same level as the Peer Support Workers. It is very important, as well, that the training of Volunteers addresses boundary issues.

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EVALUATION

The goal of the Program, to stop or to significantly reduce the spread of HIV among people who inject drugs, their families and their community, cannot be measured within the time and means of this project. That reality notwithstanding, four types of evaluation must take place within this Program to shape, measure and validate its work: iterative, outcome, process and impact.

Iterative Evaluation - Iterative evaluation is ongoing and is used to shape the work as it is being done.

Both quantitative and qualitative information about encounters and occurrences, in the form of outreach statistics, client anecdotes, material from informal discussions with service users and service providers, etc., will be collected and analysed. This data will also be incorporated into ongoing project development meetings with the supervisor and Advisory Committee and used to assess levels of awareness and needs and to inform future service provision. This will ensure flexibility and will allow the Program to respond to circumstance in a timely manner. This evaluation will take place on a regular basis, preferably weekly.

Outcome Evaluation - Outcome evaluation will be used to determine how well the Program has reached its objectives.

Focus groups of consumers will be held to address the reach, impact and effectiveness of specific program activities in meeting their objectives;

Focus groups of consumers will also be used to examine their expressed willingness to change and maintain safer behaviour and to confront unsafe behaviour among other members of their communities;

Community building (service user) will be assessed by attendance and participation at drop-ins or groups, utilisation of services, interest in Volunteer and Peer Support Worker positions;

Community building (service provider) will be assessed by the number of agencies or service providers who become engaged in community partnerships for the delivery of Harm Reduction / AIDS Prevention services;

Quantitative data will be kept on referrals to and from other agencies to evaluate number of referrals and trends;

Statistics will be kept on the number of people being reached by each activity / project, in-house or in the community, to assess utilisation of service;

Statistics on the number of harm reduction supplies distributed, either directly or through secondary means, will be recorded and examined in order to assess utilisation of service;

Statistics will be kept on the number and type of educational events and presentations; and

Statistics will be kept on unmet needs and requests for services, for current and future planning.

Process Evaluation - Process evaluations will be used to determine whether the methods and activities have been accomplished in a timely manner.

Focus testing of all materials and workshop strategies will be conducted as appropriate;

Reactive surveys will be used to measure response of participants in public presentations where Project members are speaking;

Feedback will be sought from agencies or service providers engaged in community partnerships regarding their level of satisfaction with those partnerships and the impact, if any, on their agencies;

Feedback will be sought from agencies and service providers to whom referrals have been made regarding their perception of the appropriateness, quality and "success" of the referrals.

Feedback will be sought from service users who have received referrals on the appropriateness, quality and success of these referrals.

Impact Evaluation - Impact evaluation will be used to determine how well the project has reached its goal. Impact evaluation is the responsibility of the AIDS Bureau.

It is recommended that the Advisory Committee take an active role in the evaluation of this project at all stages.

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PROGRAM LOCATION:

RECOMMENDATION - THE HOST AGENCY

We recommend that during the first year of operation of this program, community outreach emanate from a Host Agency and two Satellite Agencies.

Host Agency - Warden Woods Community Centre

Accessibility, geographic location, availability of programs and openness to harm reduction and new drug treatment strategies are some of the most important criteria in assessing an ideal location for an HIV / AIDS prevention outreach program for people who use drugs. The Host Agency should also be a workplace in which the Outreach Workers will be respected and treated equitably and get ongoing support for their work.

The intersection of Kennedy and Eglinton was identified as the ideal geographic location (there are not many drug users in that area, but in terms of travelling, Kennedy and Eglinton is smack in the middle of Scarborough); however, there are no suitable agencies in the immediate vicinity of that intersection and another location had to be found.

Waving geography to one side (to a degree) and giving weight to quality-of-service considerations, it is our recommendation that Warden Woods Community Centre be designated the host agency for this Project. There are several reasons for recommending Warden Woods Community Centre:

Warden Woods Community Centre is walking distance from many Ontario Housing projects as well as identified "hot spots".

The "hottest spots" identified by users and the police, namely the intersections at Kingston / Galloway and Danforth / Victoria Park, can be reached by car from Warden Woods Community Centre, even during rush hours, in approximately ten minutes. Moreover, the "hot spots" located in the northern neighbourhoods in Scarborough are relatively easy to drive to because of the large roads and highways leading to them.

The Program Director as well as the Youth Worker of Warden Woods Community Centre are exposed to harm reduction philosophy, are open to learning to every aspect of harm-reduction-based programming, and have voiced their commitment to provide harm reduction services within their centre.

The focus group at Warden Woods Community Centre, a group of eight young individuals, had nothing but praise for the agency. Other community members also voiced similar sentiments.

The work of Warden Woods Community Centre has been commended by staff members of various Scarborough social agencies.

Warden Woods Community Centre is accessible by the TTC, and users can access the agency by using the bus or the subway.

The Youth Worker at Warden Woods Community Centre works with drug users, has an excellent knowledge of social agencies in the area, has participated in several harm reduction workshops, and can offer exceptional assistance in hiring and guiding the Outreach Worker.

There are no traditional treatment programs at Warden Woods Community Centre.

The atmosphere at Warden Woods Community Centre is extremely convivial and hospitable.

The clientele and staff are culturally diverse.

Warden Woods Community Centre is experienced in employing community members and working with volunteers.

Though there is no medical staff at Warden Woods Community Centre, this can be compensated by referring service users to appropriate agencies or by enlisting the aid of medically credentialed volunteers.


RECOMMENDATION - THE SATELLITE AGENCIES

We recommend that during the first year of operation of this program, harm reduction sites be established at two Satellite Agencies.

Satellite Agency A - East Metro Youth Services

Reasons for selection:

The organization is open to providing services from a harm reduction perspective.

There is cultural and linguistic diversity in the agency staff and clientele. As well, it is the only organization which we encountered that has a program for lesbian / gay / bisexual youth

Youth must be an important focus of this HIV / AIDS Prevention Program, and this is a respected program.

It is easily accessible by public transportation.

Staff has indicated that they would like to host this Program.

East Metro Youth Services has several sites. It will be up to SCHAN, the Outreach Worker and the staff at East Metro Youth Services to decide where the services of this Program will be located.


Satellite Agency B - West Hill Community Health Centre

Reasons for selection:

There is a diversity of services, including medical, social work, health promotion, nutrition, etc.

As a Health Centre, its team represents a variety of disciplines, and their approach to client care is interdisciplinary.

They have a history of developing imaginative and effective partnerships.

Its location is near a major street prostitution and drug using area.

They have good relationships with sex trade workers.

Their neighbourhood has many Metro Housing developments, and the Centre has long-term relationships with them.

It is easily accessible by public transportation.

It serves culturally diverse population.

It has established outreach services to selected communities and is knowledgeable about outreach practices.

It is interested in and open to learning about harm reduction.

Another Agency which we considered is Second Base Youth Shelter. Should East Metro Youth Services not work out, this would be an appropriate alternative Satellite Agency.


BENEFITS TO HOST / SATELLITE AGENCIES

Under the inspired leadership of members of the Gay and Lesbian communities, HIV / AIDS prevention / education programs were designed to address the risks emanating from unsafe sexual behaviour. But the face of HIV / AIDS is changing. More and more people who use drugs are becoming the dominant source of new infections, and existing programs are facing having to deal with the risks emanating from unsafe drug use.

Most mainstream AIDS service organisations (ASOs) have not had exposure to injection drug users and are, therefor, unaware of the needs of drug users and not well equipped to provide services to them. Yet, since ASOs have historically been the forefront of HIV/AIDS movements, the onus has been placed on them to expand their education and prevention services to injection drug users. They have not been able to do this, because of the continuing demand for service from their historical communities of concern.

It is becoming clear that community agencies which are already working with people who use drugs are in the best position to provide these services, and that the preferred approach is from the perspective of harm reduction.

Warden Woods Community Centre, East Metro Youth Services and West Hill Community Health Centre are each strategically situated in this regard. They are connected to diverse communities which include people who use drugs, alienated youth, people engaged in the sex trade, etc. all of whom are at ever-increasing risk of being infected by HIV, not to mention Hepatitis B and C. Many of these people are already making use of their services.

The placement of this Outreach Program at these pivotal agencies will allow them to take leadership in addressing the link between drugs and these blood-born illnesses and, simultaneously, to enhance their relationships with a group of highly marginalised and very needy community members. It will provide them agencies with a new and exciting focus.

This Program will place Warden Woods Community Centre, East Metro Youth Services and West Hill Community Health Centre at the forefront of a cutting-edge community-based prevention movement. Management and front-line staff will be exposed to an innovative and challenging philosophy - harm reduction - both through training and through partnerships with other, highly experienced harm reduction based organizations, and all their work may well be enriched by this experience.

Finally, with this Outreach Program in place, the services of these agencies will be even more inclusive than they already are.


RESPONSIBILITIES OF HOST AND SATELLITE AGENCIES

The following responsibilities are to be undertaken by the Host and Satellite Agencies:

The Host Agency and each Satellite Agency, together with the Outreach Worker, will develop a local AIDS Prevention / Harm Reduction Program, in consultation with service users and community-based service providers who embrace the principles of harm reduction, to address the situations, needs, goals and objectives identified in this proposal.

The designated supervisory staff from the Host Agency will participate as a member of the Advisory Committee.

In concert with SCHAN, the Host and Satellite Agencies will actively support the pursuit of additional funding for this project from complementary sources (e.g., The United Way, ethical corporate funders, etc.), in order to provide services by the Outreach Worker, Peers, Volunteers and members of the community of concern, as identified in this document, e.g., food, transportation, additional Peer Support Workers, etc.

The Host and Satellite Agencies will encourage and support the development of partnerships with other agencies serving the community of concern.

The Host and Satellite Agencies will foster the credibility of the Program by actively promoting and advocating for it.

The Host and Satellite Agencies will provide the space and support needed for the Worker to do her / his job. This will include a computer (with Internet and E-mail capabilities, if possible) and a telephone capable of receiving collect calls. In addition, the Host Agency will provide administrative support for the Outreach Worker and the Program.

The Host and Satellite Agencies will respect the Worker's job description and not expect her or him to provide services which are the responsibility of Agency personnel.

It is expected that agencies participating in this program will have in place an anti-discriminatory policy and will have implemented a plan to achieve employment equity.

It is recommended that the Host and Satellite Agencies have access to this document.


HOST AND SATELLITE AGENCY ORIENTATION

The Host Agency administration and front-line personnel will acquaint themselves with other harm reduction programs aimed at reducing the risk of contracting HIV / AIDS for people who inject drugs.


THE RELATIONSHIP BETWEEN THE HOST AND SATELLITE AGENCIES AND THE OUTREACH WORKER

The Outreach Worker shall be respectful of the Host Agency's culture and administrative rules and protocols and to this end shall receive supervision within the Host Agency. However the Worker's service parameters shall be determined and guided by the Advisory Committee.

The Host and Satellite Agencies shall be respectful of the goal

 

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