Despite Australia having a publically funded healthcare system (Medicare), which ensures access to medical care regardless of income, some vulnerable groups may still have difficulty accessing mainstream primary healthcare (PHC) services. These populations include at risk young people, injecting drug users (IDUs) and sex workers (SWs).
Several issues have been identified that affect access to conventional PHC services for these populations. Injecting drug users report feeling that conventional services discriminate against them, either due to their injecting drug use or hepatitis C infection.1 Additionally, healthcare is often not considered to be a priority in the midst of a chaotic lifestyle where drug procurement and use and more immediate survival needs are likely to take precedence.2 This may also affect their ability to keep appointments and tolerate waiting times. The need to retain a Medicare card or provide payment may also be a barrier. Sex workers have reported similar concerns as well as ‘fear of judgment’ and ‘other patients staring’.3 Additional issues described by young people include inadequate knowledge of available services and difficulties with the processes required to access them, concerns regarding confidentiality, anonymity and embarrassment and difficulty communicating intimate concerns, as well as the perceived attitudes of health service providers and the style of the consultation.4
General practitioners have described concerns about caring for drug and alcohol patients including a lack of confidence in their ability to manage illicit drugs, concern that these patients may be ‘difficult, aggressive or demanding’, lack of time or remuneration, as well as possible disruptions to their practice.5 However, a recent Australian survey of adult patients’ attitudes toward their GP providing opioid substitution therapy found that only 18% of patients reported a disturbing waiting room experience and only 3.1% of these were due to drug intoxication. Nor was opioid substitution therapy identified as an issue causing patients to change their general practice.6
Importantly, while PHC providers are well placed to provide effective sexual healthcare, this care may be affected by GPs’ beliefs, anxieties and attitudes. In a survey of 409 New South Wales GPs, approximately 25% stated that they felt uncomfortable in dealing with SWs, IDUs or gay or lesbian patients.7 In this environment, sexually transmissible infection (STI) care may be further compromised by nondisclosure. In a survey of female street-based SWs in the United Kingdom, 62% of respondents who identified the GP as their main source of healthcare had not disclosed that they were involved in sex work.3
The fact that these marginalised populations have suboptimal access to healthcare is of particular concern given that IDUs and street-based SWs – the large majority of whom also inject drugs8 – are at risk of a range of preventable health related problems arising from their lifestyle; most notably blood borne infections including HIV and hepatitis B and C from sharing injecting equipment. They are also at risk of STIs such as gonorrhoea and chlamydia, which if untreated may lead to pelvic inflammatory disease and infertility.9
Injectors are also at risk of injecting-related injuries and diseases associated with nonsterile injecting practices. These include abscesses, skin infections, cellulitis, thrombosis, septicaemia and endocarditis.10 The drugs themselves may also have harmful effects such as psychostimulant induced psychosis and opioid overdose related organ damage and death due to central nervous system depression.11
Despite these issues, there is little published evidence to direct what type of service model is best suited to serve the health needs of these populations. A recent review concluded that there was insufficient evidence for the effectiveness of many IDU targeted PHC services to inform health service planning. This was attributed to the heterogeneity of both the PHC services studied and the types of studies undertaken.11 Van Beek12 highlighted other reasons for a dearth of research in this area including complex methodological challenges and the fact that PHC services serving these populations are rarely funded to undertake rigorous service evaluation. However, this paper also argued that the lack of high level research evidence should not be equated to ineffectiveness and should not detract from the essential activities that many PHC services deliver to these vulnerable populations.12
The Kirketon Road Centre
The Kirketon Road Centre (KRC) in Kings Cross, Sydney (New South Wales), is an integrated PHC service that provides comprehensive care to at risk young people, IDUs and SWs across the wide range of health and social welfare needs of these patients13 (Table 1). The KRC was established in 1987 as a result of a recommendation of the Select Committee of the Legislative Assembly on Prostitution, Parliament of New South Wales, whose findings were published in the Rogan Report in 1986.14 The committee recognised that existing STI clinics were ‘not well adapted to the needs of prostitutes and may in fact be avoided’ and suggested that ‘… these problems could be overcome by establishing a centre with more flexible outreach and ‘drop in‘ services that would be fully accessible and acceptable to sex workers’.
nder the banner of ‘health for all’, the KRC has adopted the principles of PHC outlined in the Declaration of Alma-Ata including a focus on acceptability, accessibility, affordability and equity in healthcare provision.15 The centre has a population focus rather than a disease-specific focus, which was considered to be in keeping with a holistic approach and KRC’s public health objective of preventing and treating HIV/AIDS and other transmissible infections in the at risk target population.
Table 1. Clinical services at KRC
- Assessment and management of general health issues
- HIV antibody testing/pre- and post-test discussion
- HIV/AIDS medical management and counselling
- Hepatitis A and B testing and vaccination
- Hepatitis C testing, monitoring and treatment
- Healthy liver clinic with specialised hepatitis service
- Sexual health testing and management of STIs
- Sex worker information and check-ups
- Women’s health checks, including Pap tests and breast examinations
- Contraception, pregnancy testing and advice
- Drug and alcohol counselling, assessment and referral
- Crisis intervention/support and counselling for emotional issues
- Housing, social security and welfare information and assistance
- Podiatry clinic
- Methadone access program incorporating case management
- Needle and syringe program
- Outreach program, street van and bus
To ensure access in a setting when sensitive and often illicit behaviours need to be recorded in medical files, the KRC operates outside of the Medicare arrangement and uses an anonymous registration system that does not require verification of personal identification. This system ensures confidentiality of client consultations to a level beyond the standard confidentiality of health information requirements in Australia.
In order to encourage access for our target population, the clinic has a nonidentifying service name and innocuous street frontage (Figure 1) and maintains a warm, nonclinical service atmosphere.13 The clinic operates within a harm reduction framework where clients’ lifestyle choices are respected. While clients are not necessarily required to address their level of drug consumption, great emphasis is placed on informing clients of the risks inherent in their lifestyle and how to reduce the potential harms associated with these choices.13
To date, KRC has registered close to 40 000 individual clients. In the past 12 months, 22% of occasions of service at the clinic were with at risk young people, 57% with IDUs and 40% with SWs. The centre sees up to 70 clients per day for issues that include sexual health (34%), drug and alcohol (14%), HIV and hepatitis (9%), counselling/ psychosocial services (25%) and general medical care (18%). The KRC also dispenses methadone treatment to about 60 IDUs per day and sterile injecting equipment (through its needle and syringe program) to about 100 IDUs per day.
Figure 1. Kirketon Road Centre
While there will always be a need for targeted services such as the KRC in locations like Sydney’s Kings Cross, GPs are well placed to address many of the health needs of similar vulnerable populations.
Providing vital clinical services
General practitioners can provide vital clinical services to at risk young people, IDUs and SWs including opportunistic HIV and hepatitis B and C testing as well as hepatitis B vaccination, testing for STIs such as gonorrhoea and chlamydia and advice on cervical screening and contraception. In addition, GPs are often the first contact for entry into drug treatment programs. Therefore, it is useful for all GPs to have links with their local drug and alcohol services as well as basic knowledge of the evidence demonstrating the benefits of opioid dependence treatment with pharmacotherapies such as methadone and buprenorphine. Currently, authority to prescribe such medications must be obtained from your local state drug and alcohol regulatory body and may involve additional training. However, in New South Wales there is provision for all GPs to assume responsibility for ongoing methadone prescribing for up to five patients already stabilised on methadone treatment without the need to undertake specific pharmacotherapy training. The recent introduction of the coformulated buprenorphine naloxone sublingual film (Suboxone®)16 for opioid dependence will potentially make this more manageable in general practice.
While it may not be possible to provide some methods of engagement similar to drop-in clinics or outreach programs from a general practice setting,3,4,8,13 it may be possible to fast track or prioritise certain patients, in particular young people. It may also be feasible to offer a more flexible drop-in appointment system for patients who are known to the service but may have some difficulty keeping scheduled appointments (eg. routine methadone prescriptions).
Offering bulk-billing, which will often include Medicare Item 10990 (a service provided to a Commonwealth concession card holder), will also make PHC more affordable to these vulnerable populations. Chronic Disease Management Medicare item numbers (721 to 732) may also apply to many of these patients.
Arguably more important than any other issue is the need to have a nonjudgemental approach when dealing with vulnerable populations, particularly as this has been widely identified as crucial in the engagement of those who have often suffered various levels of discrimination within health services.1,2,4
Conflict of interest: none declared