Introduction
The Vancouver Native Health Society (VNHS) Medical Clinic was established in 1991 to improve access to medical services for urban First Nations people. It is a non-profit, provincially funded health centre located in the most impoverished community in Canada. Known as the Downtown Eastside, this area of Vancouver has an estimated population of 16,275 and is the home for about 4700 injection drug users.[1,2] The epicentre of the drug trade is located 3 blocks from the medical clinic at the corner of Main and Hastings streets. Here trafficking of both illicit and prescription drugs and injection drug use occur openly.

The population of the Downtown Eastside is very diverse. It consists of many thousands of mentally ill, homeless, single elderly men, immigrants, troubled youth, and Aboriginal people. The community is experiencing epidemics of HIV/AIDS, hepatitis, tuberculosis, and syphilis, has among the highest HIV infection rates of any community in the Western world, and the highest mortality rate in Vancouver, with premature death being the norm.[3,4] These epidemics are the result of the decay of all the determinants of health. The main factors include poverty, social isolation, drug dependency, violence, crime, unhealthy physical environment, low education levels, the sex trade, mental illness, and limited access to addiction treatment.

Health services
Providing health care to residents of Vancouver’s Downtown Eastside is very challenging. Many individuals are survivors of severe childhood trauma. Negative experiences such as family violence, parental substance abuse, sexual and emotional abuse, suicide, divorce, and residential school atrocities are the norm, and most residents suffer from low self-esteem. Trust is slow to develop, and forming a cohesive doctor-patient relationship can take years. Continuity of care is essential to foster this relationship.

Interactions can be strained, as the physician must be alert to drug-seeking, manipulative, and violent behaviors. Potentially dangerous incidents must be expected and managed appropriately. Police and ambulance interventions at the clinic are frequent. This atmosphere results in substantial work-related stress, and staff turnover is high.

Traditional approaches to health care are ineffective in this setting, so services are tailored to meet the needs of our patients. The services at VNHS include primary, nursing, psychiatric, and HIV/AIDS care, addictions and methadone maintenance treatment, outreach, and phlebotomy. Appointments are not necessary and the clinic is open every day. VNHS is a clinical teaching site for medical and nursing students from the University of British Columbia. The medical staff includes five male and four female physicians and a nurse.

Methadone maintenance
The methadone program follows a harm-reduction model. Two alcohol and drug counselors provide support for the program. A methadone support group, Narcotics Anonymous meetings, and ear acupuncture for addiction are available. At some time in 1999, 171 patients were on methadone; 58% were men and 40% were women. White men on methadone outnumbered Aboriginal men 6 to 1. The distribution for women was quite different; an almost equal number of Aboriginal and white women were on methadone. Current enrollment in the methadone program is 65 patients.

Support services
In addition to methadone maintenance treatment and simplified HIV treatment schedules, the clinic attempts to attract and retain patients in treatment by offering multiple support services. The clinic works closely with the staff of the Native Health Society’s Positive Outlook HIV/AIDS drop-in centre located next door, with the Vancouver/ Richmond Health Board’s Maximally Assisted and Directly Observed therapy programs, and with Vancouver/ Richmond Health Board home-care nurses. Using a case-management model, the Positive Outlook staff provides care, outreach, counseling, social work, and advocacy for hundreds of HIV-positive people.

Individuals are encouraged to attend the drop-in centre to have lunch, socialize with peers, watch videos, or receive education. The drop-in centre staff dispenses and monitors HIV medications and coordinates transportation to appointments and hospital. Many very ill and highly dysfunctional individuals are effectively managed with these services. In an effort to heighten HIV/AIDS and alcohol and drug awareness, and to enhance medication compliance, low literacy teaching materials were developed.

Epidemics
The Vancouver Injection Drug User Study (VIDUS) showed that about 33% of the injection drug users in the Downtown Eastside are HIV positive. A history of intravenous cocaine use was the strongest predictor for HIV infection, and Aboriginal people were at an increased risk.[5] Nearly all of the HIV/AIDS patients at VNHS suffer from either heroin and/or cocaine dependence.

In this community, hepatitis C transmission is largely through shared injection paraphernalia. The VIDUS investigators estimated hepatitis C prevalence in injection drug users to be 86%.[6] Indeed at VNHS, every injection drug user is assumed to be infected. Hepatitis C infection can increase the toxicity from antiretroviral therapy, and in some cases treatment must be discontinued. In addition, chronic hepatitis C increases the risk of liver dysfunction, cirrhosis, and hepatocellular carcinoma, so the resulting morbidity and public health consequences of this epidemic will be profound.

Syphilis is a sexually transmitted disease that can affect any organ and can spread vertically from a pregnant mother to her developing fetus. Syphilis can cause congenital abnormalities and serious multi-organ sequelae. It usually begins as a genital ulcer that is believed to facilitate the transmission of HIV. The syphilis epidemic began in 1997 and is focused in the Downtown Eastside. Since July 1997, the British Columbia Centre for Disease Control has identified 225 cases of syphilis.[7-9] The epidemic appears to be continuing because of the sex trade, high-risk sexual behavior, and obstacles to contact tracing.[8]

Tuberculosis is also on the rise, particularly among individuals with HIV/AIDS and Aboriginal people. The incidence in the Downtown Eastside is estimated at 77.5 per 100,000 people; more than 10 times higher than the national average of 7 per 100,000. Also increasingly prevalent is a highly resistant strain of bacteria: methicillin resistant Staphylococcus aureus.

Statistics
The clinic had 15,669 visits in 1999. The total caseload was 3829 patients; 50% were white, 40% were Aboriginal, and Hispanic, black, and Asian patients accounted for about 3% each. The majority of Aboriginal people were status Natives living off reserve, accounting for 73% of all Aboriginal patients. Non-status Aboriginal patients accounted for 19% and Metis 8%.

HIV/AIDS
The clinic saw 353 HIV-positive people in 1999. The overall prevalence of HIV for all patients that attended VNHS was 9.2%. The prevalence of HIV for males was 9%, for females it was also 9%, while the prevalence for transgendered individuals was 40% (6 of 15).

The statistics indicate that Aboriginal people are at greater risk for contracting HIV than non-Aboriginals. Twelve percent of the Aboriginal males and 11% of Aboriginal females were HIV positive, while the prevalence for white males and females was 9% and 7% respectively. Aboriginal transgendered people were the highest-risk group at 63% (5 of 8).

Overall, males accounted for 64% of HIV-positive clinic patients, females 34%, and transgenders 2% (Figure 1 [9]). The patients ranged in age from 16 to 64 years.

Antiretroviral treatment
The unique frame of reference of this community requires modification of every aspect of HIV/AIDS care. Risk assessment, pre- and post-test counseling, contact tracing, treatment goals, adherence strategies, and prognosis must be adapted to meet the needs of this population.

HIV/AIDS therapy involves multiple medications taken in combination for extended periods of time. These medications, collectively called antiretroviral therapy, act at multiple sites of viral reproduction to specifically interfere with viral replication. Adherence is crucial to reduce the chance of viral resistance. Traditionally, antiretroviral regimes have been complex, but recently many antiretrovirals have been effective when dosed twice and in some cases once a day, so it is now possible to offer more simplified regimes.

Side effects are frequent with all regimes, and regular clinical follow-up and hematological monitoring are essential. Given these obstacles, long-term compliance with treatment is extremely difficult to achieve for this population. Indeed, the majority of our HIV/AIDS patients, 68%, were not on antiretroviral therapy in 1999. Of the patients on antiretroviral therapy, 66% were male and 32% were female. Aboriginal patients tended to receive antiretroviral therapy less often than white patients (29% of male Aboriginal patients and 27% of female Aboriginal patients compared to 37% of white male patients and 34% of white female patients).

Some individuals and HIV/AIDS advocates have suggested that many patients in the Downtown Eastside have been denied access to antiretroviral therapy because of ongoing substance abuse and a precondition of abstinence or drug treatment (i.e., methadone). However, our statistics indicate that the majority of patients (69 of 111) on antiretroviral therapy were not on methadone (Figure 2 [10]). Indeed our experience has been that substance-dependent individuals often choose to delay treatment until their substance abuse problem is under control.

When adherence to antiretroviral therapy is jeopardized because of substance abuse or mental illness, treatment is focused on stabilizing the patient’s addiction or mental state. Methadone maintenance treatment is one strategy used to assist heroin addicts to stabilize their lives and improve their chances of successfully adhering to antiretroviral therapy. Of the 67 HIV/AIDS patients on methadone, 63% were also on antiretroviral therapy. This needs to be compared to the 286 HIV/AIDS patients not on methadone, where 24% were on antiretroviral therapy (Figure 2 [10]).

Some patients wish to pursue antiretroviral therapy while still actively using illicit drugs. In these circumstances, long-term viral suppression and immune reconstitution can still be achieved, and these patients should not be denied access to antiretroviral therapy. Clinical judgment, along with reports from support staff and laboratory evidence, must be used to assess treatment outcomes because the ability to predict adherence in such individuals is so variable.

Mortality
The clinic was notified of 38 deaths in 1999. The leading causes of death were complications of HIV/AIDS (34%) and overdose (29%). The median age at death for all causes was 38 years. The median age at death due to overdose was 35 years, versus 41 years for HIV/ AIDS.

Analysis
Although our sample size is small, transgendered individuals, especially Aboriginal people, are at exceedingly high risk for HIV. The most likely reasons for this are involvement in the sex trade and the associated high-risk sexual behaviors (i.e., anal intercourse) and concomitant IV drug use.

The majority of HIV-infected and drug-dependent individuals in the Downtown Eastside remain untreated for their diseases. In addition to being at the greatest risk for HIV, Aboriginal people were less likely to be on antiretroviral therapy and Aboriginal men accounted for the smallest percentage of patients on methadone. A number of factors may explain this. Cultural and lifestyle differences likely exist in regards to desire for treatment. Fewer Aboriginal people may be aware, or accepting of, available treatment. Alcohol, and not heroin, may be the drug of choice for the majority of the substance-dependent Aboriginal people, so fewer sought methadone maintenance.

The mortality statistics highlight that complications of HIV/AIDS are the leading causes of death, and premature death is the norm among the patients seen at this clinic.

Discussion
The health status of the residents of the Downtown Eastside is among the worst in Canada, and Aboriginal people are at the greatest risk for disease. To be effective, treatments must be accessible, respectful, simplified, and offered with addiction care and ancillary services. Ultimately, raising the health status of this community requires long-term strategies that positively impact upon the prime determinants of health—only then will the epidemics of HIV/AIDS, hepatitis, tuberculosis, and syphilis be abated.

Provincial health divisions must take responsibility for Aboriginal health issues, and Aboriginal health must be a priority of the provincial government. The recently approved Aboriginal health plan provides a framework for discussion and action; however, current funding shortfalls for agencies providing services for First Nations people living in the Downtown Eastside must be corrected.

Dr Adilman is the clinic coordinator at the Vancouver Native Health Clinic. Mr Kliewer is the clinic nurse at the Vancouver Native Health Clinic.