Questions/Answers

The initiative aims to resolve a gap in giving the appropriate health care to people who are at risk and especially vulnerable, to HIV infection, viral hepatitis and sexually transmitted infections in the Lisbon region. Lisbon and Tagus Valley Regional Health Administration (ARSLVT) is responsible for all primary, secondary and continuity of care to 3.653.217 habitants on the geographic region of Lisbon and Tagus Valley. Our strategic action vectors points to promoting and give the best health care to all population, among others. Recognizing the gap in our services, we turn to have it resolve through a strategic agreement with civil society representatives. It turns possible to have the agreement with Cabinet of Treatment Activists (GAT) that is aiming to ensure community-based screenings through all the country. As well as ARSLVT, they try to have screening actions for sex workers, homeless people, and migrants, including those persons residing legally or illegally in the country. GAT are using community based rapid testing (CBRT) for screening at risk population and those marginalized or with less access to care facilities.

We consider the initiative we are presenting under the first category. As a public service we know that sexual orientation and gender identity are social determinants of health, and understand that health disparities occur among sexual, and minority populations. They are at risk populations for such diseases as AIDS/HIV, viral Hepatitis, Syphilis and other sexual transmitted diseases. However, as a public service we recognize that we do not have the appropriate access for such a population, nor the appropriate means to solve the problem. The strategic partnerships with GAT presents the opportunity to grant inclusive and equitable services and not leaving no one behind.

We align our initiative with the third development goal “Healthy lives and promote well-being for all”, especially those at risk or AIDS/HIV, viral Hepatitis, and Syphilis. The strategic partnership is directed for homeless, people who use drugs, sex workers, men who have sex with other men, and migrants. We are trying to contribute to an “universal health coverage” and try to give access to quality essential health care services by screening and referral capabilities, either to primary or secondary care. This “early warning, risk reduction” is gaining momentum by the progressively better results we are achieving.

Knowing that strategic partnerships with civil Society groups play an important role in efforts to address HIV and AIDS, viral Hepatitis, and Syphilis as other sexual transmitted diseases ARSVT looked for a partner in the field. We know that those people who use drugs, sex workers, men who have sex with other men, migrants, and are homeless are of difficult screening by conventional services – either primary or secondary care - and are dealing with increased health risks. GAT turns possible this kind of strategic partnerships, and the access to those at risk, as they are developing Community Screening Networks in Portugal. Their view is to implementing a national rapid screening network with the collaboration of lay people and professional supervision. The ARSLVT, through their public health services and unities of care is unable to screen people who use drugs, sex workers, men who have sex with men and migrants, not only because appropriate workers are unavailable, but also because don’t have the appropriate means. Partnership with GAT turns out possible to address this gap in our public service.

Innovation comes out from the possibility of: • Having access to people that traditionally are unavailable to health institutions in a way that preserves their identity. • Using screening tests that are cost efficient (CBRT) • Referring more and more patients (people who use drugs, sex workers, men who have sex with men and migrants) to Primary Health Care and Hospitals. • Have those patients supervised by public health services and accompanied in the community. • Doing such a strategic partnerships with civic society representatives.

There are other strategic partnerships initiated, either in our country or in our Region, but as far as we know, not in this field. The acceptance of this by ARSLVT, in the first moment, and our interest in maintaining and deepen it, comes from the lessons learned from the practice and recognition that it is the way to address the problem.

GAT is working with more 16-community associations, all from the social sector, none of them public or private health services. ARSLVT thinks it is desirable to have the initiative transferred, because there are the same health problem through all other portuguese regions.

ARSLVT have a 20-hour monthly professional to control the partnership activities. Annual contract: 12,673 screenings, 1,660 medical and 3,250 nursing consultations. Annual compensation: 336.743€ each year. GAT has invested approximately 30 people in CBRT to: counselling and with written information delivery, condoms distribution, lubricants and risk reduction kits, criteria for screening, use of rapid antibody / antigens, post-exposure and pre-exposure guidance prophylaxis, orientation for partner notification referral of reactive cases to hospital, and facilitation of self-help groups. Health professional: sexual health evaluation and sampling for the laboratory, prescription of preventive treatment, administration antibiotic and / or vaccine, monitoring of users of pre-exposure prophylaxis, referral for hospital, and reporting of notifiable diseases.

• ARSLVT’s (the State) supports the direct costs of CBRT and screenings. • Donations, grants, and prizes (from municipality, international organizations, pharmaceutical companies) are used to support follow up activities that promote people adherence to treatment, health literacy, transportation, meals, medicines (other than those provided free of charge at the hospital), and fees for other health services (co-morbidities are common). • All activities comply with environmental protection regulations and additional steps are taken to lessen environmental impact (e.g., use of energy efficient equipment wherever possible). • Adherence to CBRT are increasing. Informing and empowering individuals helps spreading information about health and rights, increasing the effectiveness of the investment. Increased health literacy ensures healthier people and communities; informed empowerment promotes participation towards informed decision-making, better policies and tailored, effective services.

Yes

There is an annual evaluation of the agreement. The contract between ARSLVT and GAT dates from July 2017. A report including 2018 first trimester is available (annex).

There are two production lines: community-based screening sessions and medical and nursing consultations. Their numerators: • Estimated and executed number of screening sessions • Number of people referred to hospitals (within 24 hours) • Number of people referred to Primary Health Care • Highest weight of rapid tests (HIV, Syphilis, and Hepatitis) • Cost per rapid testing session in primary care clinical settings vs. cost per CBRT session • Cost per infection found in primary care clinical settings vs. cost per infection found via CBRT sessions

• Strengthened partnership between government and civil Society • Since the progressive acceptance of GAT by the target population, it results in more and more consultations (medical and nursing). • Increased program effectiveness as it presents more hospital and primary care referrals. • Negotiation of more activity between Gat and ARSLVT represents mutual acceptance and confidence. • Increased access of socially marginalized populations to health care helping to reduce the prevalence of sexually transmitted diseases and improving the health status of the populations covered. • Wider commitment to HIV and AIDS and improved understanding of the local social and cultural context, resulting in engaged and mobilized communities

A Primary Health Care transformation has occurred in Portugal, and since 2006 there are Family Health Units and other resources for health promotion and prevention in all municipalities, along with Public Health Units and community care units. Although the attempts made by the state in order to get a doctor for every citizen at the Primary Care level, there are people that cannot get access to a doctor. It is the case of migrants, sex workers, trans genders, homeless people and others. In order to solve the problem ARSLVT made an innovate agreement in order to get people under control of health care situations like TB, HIV, viral hepatitis, and syphilis. By an outcome based model with GAT, ARSLVT grants a service complementary to the National Healthcare Service (NHS), in order to support CBRT. GAT has begun offering CBRT, and always valued academia and the scientific community close ties, promotes the training and involvement of individuals from the populations most affected by the HIV pandemic, and networks with community organizations (promotes, and partly finances, the award-winning national Community Based Screening Network). GAT has always advocated for evidence based policies and sustainable healthcare financing models, both requiring participated, objective evaluation models.

• This collaboration highlights: o The value of key-population oriented CBRT when considering both cost-effectiveness and public and individual health gains (lessens late diagnosis, and decreases transmission via a test-and-treat approach). o Proved valuable in promoting better articulation between community-based organizations and the NHS. o Trained lay people can do the job, along with professional supervision. o Provides greater control over pandemic and epidemic diseases