2/23/2016
OBJECTIVES
Through case presentations explore primary care
in HIV positive women
 Address importance of harm reduction, mental
health and addictions treatment as it applies to
holistic well being
 Explore the levels of interdisciplinary care and
necessity of accessing community support
 Provide practical and realistic approach to
managing women living with HIV in
Saskatchewan
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PRIMARY CARE OF
LIVING WITH HIV
WOMEN
PRENATAL CARE AT WESTSIDE CLINIC
RULES OF ENGAGEMENT
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Building trusting relationships
Safe, non-judgmental environment
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Primary care provides anonymity
NEVER ASSUME
 Continuity of care
 Door is never closed
 TEAM, TEAM, TEAM
 Opportunistic care
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2/23/2016
BARRIERS TO CARE
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“…[women with HIV and addictions] often show
high uptake of health and social services, yet
limited attention to HIV care, with only 9% of
women on antiretrovial therapy.”
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Inherent biological vulnerability
Social determinants of health
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Poverty, homelessness, food security, education,
transportation, etc
Increased sex trade work and inability to prevent
pregnancy/HIV transmission
HIV/Addictions stigma
Addictions and limited access to non-judgmental care,
harm reduction and treatment
Co-morbidities (FASD, ADHD, abuse, mental health)
Expectations as family caregiver (limited childcare,
etc)
Limited financial resources/unequal economic power
Geographical location
Confidentiality
Shannon, K., et al., Access and utilization of HIV treatment and services among women sex workers in
Vancouver’s downtown eastside. Journal of Urban Health, 2005. 82 (3): p. 488-497.
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CASE PRESENTATION – 22 YEAR OLD
CONT’D
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2014 - employed in health region and attending
school; IUD inserted for contraception
difficulty with relationship and begins using crack
and THC
Family history of addiction and active drug use in
family members, including her mother; FASD
Began to engage with counseling services and
accessing detox facilities but difficulties coordinating
Increasing drug use throughout 2014
Engage with psychiatry due to depression, ?bipolar
disorder and a history in childhood of ADHD
Psychiatric medication initiated
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Attempts made to access treatment facilities for addictions
– difficulty coordinating between counseling/outreach
worker/psychiatry
November 2014 – positive HIV POC test but long draw
negative – lost to follow-up for a couple of months
2015 – attends Calder centre and completes treatment
program; is 35 days sober and planning to attend Cree
Nation treatment facility
Returned from treatment and relapsed
Began using CM IV
August 2015 – pregnant – HIV+ on prenatal bloodwork
Initially decides to have TA and then lost to follow-up
Re-engaged in care October 2015
Prenatal visits started, HIV medication started, attending
treatment centre and working with Social Services to plan
care for child once born
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PRIMARY CARE FOR HIV POSITIVE
WOMEN
Primary health care
 Contraception
 Pap testing
 Treatment for STIS
 Disclosure/relationships
 Care of children and family member
HIV Care
 Pre-test/post-test counselling
 Bloodwork
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HIV infection – CD4 counts, viral loads, genotypes
Co-morbid conditions – Hepatitis, TB, STIs
Immunizations
 ARV Medication initiation
 Linkage with Positive Living Program/Infectious Disease Specialist
Prenatal Care
 Regular consistent follow-up
 Connection with intensive case management
 Linkage with Obstetrical care
 Notification to hospital and planning for medications for mom/baby upon
delivery
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METHADONE
Stop the chaos/normalcy to day to day life
Engagement with addictions/detox and care
 Linkage with daily ARV therapy
 Decreased transmission
Mental Health
 Counseling
 Addictions outreach
 Treatment facilities
 Needle exchange
 Psychiatry
Community linkages
 STC for cultural, outreach, health care support
 SS for family planning
 Supportive living/My Homes/Infinity House/Baby
Steps/NIWA/
 Pharmacy (PLP and community)
CASE #2
18 yo female – pregnant (2003)
Unengaged in care after pregnancy – heavily street
entrenched (2004-2007)
 HIV/Hep C positive diagnosis 2007 at time of second
pregnancy – started on ARVs – incarcerated at end of
pregnancy and delivered HIV negative baby
 Engaged with ID specialist once during pregnancy
 History of physical/sexual abuse from ages 5-12 from
stepfather and grandfather; sex trade at age 15;
alcohol use early in life and led to IV cocaine and
morphine use
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2/23/2016
CONT’D
Methadone initiated 2008
Multiple infections, STIs, pyelonephritis,
osteomyelitis, ER visits and admissions
 Anxiety and depression beginning at early age
 Held captive/beaten and resulting nightmares –
connected with psychiatry in 2011
 Complete Calder treatment 2012
 Started methadone again at MARS – able to
restart ARVs (CD4 count 64 at that time)
 Several medication starts and stops
CONT’D
Auditory/visual hallucinations and paranoia
Suicide attempt 2013 – difficulty accessing
mental treatment because symptoms blamed on
drug use
 Trial of group home but difficulty because of
mental health – linked with CMHN
 2014 – found in river after jumping; miscarriage
at this time
 Started depo psych meds at this time
 March 2015 - 9 months later off drugs, mentally
stable, taking ARVs (CD4 count 5)
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CONT’D
SOME QUOTES…
September 2015 – advancing cervical cancer –
total hysterectomy – started on dilaudid for pain
– relapse
 Connected with intensive outreach, CMHN and
restarted on methadone
 No drug use for 2 months, CD4 count 97, viral
load 600, taking ARVs
17 yo new diagnosis HIV – positive for Hep C,
chlamydia, gonorrhea, herpes and vaginal warts
– advised of all findings:
“now…how am I supposed to live the rest of my life
in this body?”
 30 yo when asked how long she had been free
from drug use:
“9 months and on the street…I didn’t even need to
go to jail or have a baby to do it!”
o “I want to use more than I want this baby. I
thought I would die doing this and this is not how
I would be clean, not by being pregnant.”
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