Programming Connection

HIV Prevention Clinic 

Toronto General Hospital
Toronto, ON
2017

How Does the Program Work?

The HIV Prevention Clinic operates within an inter-professional HIV clinic at TGH.  TGH is part of a group of four hospitals called the University Health Network (UHN). The HIV Prevention Clinic team, which operates one to two days per week, includes one HIV specialist physician, three nurses, two social workers, and access to the psychiatrist and pharmacist associated with the Immunodeficiency Clinic.

The HIV Prevention Clinic is purposefully designed to be a speciality clinic, where clients can access a number of experts in biomedical and psychosocial HIV prevention in the same place. Having different types of care providers in one clinic, all of whom are experts in PrEP, PEP, and HIV prevention, is an integral component of the service.

One of the goals of the clinic is to reduce barriers to services. One of the ways that it tries to achieve this goal is by maintaining a short- or no-wait time policy for clients (meaning, there is no or limited waiting once a client arrives in the clinic).

Referrals and community engagement

Emergency departments: Primary referral source for PEP

Typically, people accessing the HIV Prevention Clinic for PEP are referred from a local emergency department, and particularly from one of the emergency departments within the University Health Network.

The HIV Prevention Clinic has engaged each emergency department in the UHN to streamline their PEP process by using a PEP protocol. The PEP protocol has very clear instructions on what to do when a person presents with a potential HIV exposure, including which tests to order and which medications to administer. The protocol states that the client’s referral be sent directly to the HIV Prevention Clinic. The direct referral helps to ensure linkage to follow-up care after the client leaves the emergency department.

The streamlined PEP protocol and outreach carried out by the HIV Prevention Clinic physician to these emergency departments has made PEP provision incredibly easy for physicians in emergency departments in Toronto. It also allows emergency doctors to know that when a PEP client leaves the emergency department, they will continue to receive care.

The HIV Prevention Clinic physician engages emergency departments in an ongoing way, given staff turnover in these departments.

Sexual health clinics and primary care clinics: Primary referral source for PrEP

Referrals to the HIV Prevention Clinic often come through sexual health and primary care clinics. The HIV specialist physician and social workers at the clinic have carried out extensive outreach and education to service providers in sexual health and primary care clinics. This outreach has leveraged the good reputation of the Immunodeficiency Clinic at TGH to promote the comprehensive services and non-judgemental nature of the HIV Prevention Clinic.

As with emergency departments, care providers in these sites are provided a simple referral process to make it as easy as possible for them to refer their patients to the HIV Prevention Clinic. The outreach to these providers by a fellow physician and/or social worker has been very important for the success of the clinic. Sexual health and primary care providers respond well to outreach from other healthcare providers.

When a client is referred by a care provider, the client contacts the HIV Prevention Clinic for an appointment.

General services offered at the HIV Prevention Clinic

The HIV Prevention Clinic provides holistic services for all clients. This is not limited to HIV prevention services such as PEP and PrEP. Although clients are referred because they may benefit from PEP and PrEP, the clinic also provides other appropriate healthcare services. The team screens and vaccinates for hepatitis A and B; screens for hepatitis C; evaluates clients for other common health conditions; and coordinates services with other relevant care providers in areas such as mental health and drug dependence.

One of the goals of the clinic is to be as low-barrier as possible. When a client visits the clinic for their first appointment, they typically do not wait for more than a few minutes before seeing the physician and nurse. This is considered an important element of the culture and feeling of the HIV Prevention Clinic. The staff are friendly and try to minimize the stress of an appointment.

The HIV Prevention Clinic offers multiple services onsite to clients, which would otherwise have to be performed at other health care clinics/sites. This includes blood draws, urine tests, and swabs for sexually transmitted infection (STI) diagnostic testing.

Critically, there is a pharmacy in the clinic, which makes immediate access to PEP and PrEP drugs possible. This direct access to the pharmacy means that the client can avoid having a conversation with an external pharmacist about the medication and why they are taking it, which may reduce one barrier to PEP and PrEP.

Clinic staff, including the specialist physician, are committed to spending as much time with clients as they need, a unique feature for a busy healthcare clinic.

Psychosocial support at the HIV Prevention Clinic

Both PEP and PrEP clients can engage in the psychosocial support services provided by the two social workers at the HIV Prevention Clinic. Psychosocial support includes counselling for mental health and substance use, counselling for those who are diagnosed with HIV, counselling related to relationship issues, and support for other HIV and non-HIV related issues.

Education outreach

In addition to the clinic’s mandate to provide comprehensive HIV prevention services to people at risk for HIV, they also strive to provide education about the provision of PEP and PrEP to physicians. Specifically, the clinic works to educate primary care physicians on their role in PEP and PrEP provision and support for HIV prevention among high-risk communities. Decentralized biomedical HIV prevention services available outside of TGH is the ultimate goal of this education outreach.

PEP services

When a person presents to the emergency department with a potential recent exposure to HIV and is assessed for PEP, the client takes the first dose in the emergency department and leaves with a prescription for up to one week of PEP medications. Staff instruct the client to continue to take their PEP medication while they wait for their appointment at the HIV Prevention Clinic. The HIV Prevention Clinic receives a referral and sees the client within the week.

When a PEP client first visits the HIV Prevention Clinic, they engage in an inter-professional needs assessment. The HIV specialist physician provides extensive education around PEP, HIV prevention, and HIV transmission. The HIV specialist physician and nurse evaluate the client’s clinical HIV-related needs, which includes listening to the story of the potential HIV exposure and determining if the client should continue on PEP. They also evaluate the client for other medical conditions and issues, such as vaccine preventable illnesses and STIs. Finally, the nurse or physician and client discuss their ability to cover the cost of PEP for the full month. If the person is unable to pay for PEP, a social worker works with them to develop a strategy to ensure that they can access the medication (see below).

The nurse or physician also provides an initial non-clinical assessment and links clients who require psychosocial support to one of the team’s social workers. The social worker provides a more thorough mental health assessment, provides short-term counselling, and refers the patient to other mental health and community services, such as drug treatment programs, as appropriate.

Clients are expected to come back for follow up appointments when the month-long treatment for PEP is finished. They are also expected to return four months and six months after the end of the 30-day PEP treatment. Most clients return for these follow up appointments.  At these appointments, clients are screened for HIV and other STIs, and general mental health assessments are conducted with referrals as appropriate. 

Transitioning to PrEP

During PEP follow-up visits, the HIV physician assesses the client for PrEP. If PrEP seems like a good HIV prevention option for the client, the physician and client discuss the opportunity to start PrEP.  The clinic has transitioned many eligible clients from PEP to PrEP. In some cases, when a client is eligible for PrEP, but not interested, the HIV physician often continues to meet with them (approximately every three months) to continue the conversation about PrEP and HIV prevention and support their mental and physical health.

PrEP services

Patients seeking PrEP first meet with the nurse and physician to have a basic physical assessment, including HIV and STI testing and a discussion about their HIV risk and the reasons they want PrEP.

Clients may be considered good candidates for PrEP if they have any of the following risk factors:

  • have had sex with a partner who has HIV
  • have had a recent STI
  • have multiple sexual partners with a history of inconsistent or no condom use
  • currently involved in sex work
  • have had repeated courses of PEP

During the first appointment, the physician provides a comprehensive education on PrEP, HIV transmission, and HIV prevention. When a client is considered a good candidate for PrEP, the nurse and client discuss the client’s ability to pay for it. If the person is unable to pay for PrEP on their own, one of the social workers works with them to develop a strategy to access coverage for the medication (see below).

If PrEP is right for a client—as determined by the healthcare team and the client-- they receive a prescription for three months of daily Truvada, which they can access that day (or at a later date if payment is an issue) from the HIV Prevention Clinic pharmacy. This is in line with the U.S. clinical practice guidelines for PrEP. Canadian guidelines will be available in 2017.

Follow up for a client on PrEP

Clients on PrEP have to return to the clinic every three months to receive a new prescription. This return visit includes HIV and STI screening, and a physical and mental health check-up. HIV screening is critical; if a client acquires HIV while on PrEP, and they continue taking PrEP medications as if they were HIV negative, they may develop resistance to the medication, which is also used to treat HIV. STI screening is also important because PrEP does not protect against STIs. When detected, STIs are treated at the clinic. The three-month appointment schedule also provides an opportunity for the healthcare team and the client to confirm the ongoing need for PrEP and to address any other health concerns.

If a client does not schedule an appointment to renew their prescription or does not show up for their appointment, the HIV physician follows up with phone calls.

Paying for PrEP and PEP medication

In Ontario, PEP and PrEP are not covered by the public insurance system. The HIV Prevention Clinic’s social workers have extensive knowledge of private and public insurance plans/systems in the province. This is a critical skill in supporting relatively quick and easy access to PrEP for patients who cannot pay out of pocket.

For those who need financial support to access PEP or PrEP, the social workers can help them navigate the insurance system. They are able to answer questions from clients who are only partially insured (e.g., if insurance covers 80% of the cost of the drugs). This is critical to reducing barriers to these HIV prevention tools.