Programming Connection

The Maple Leaf PrEP Clinic 

Maple Leaf Medical
Toronto, ON
2019

How Does the Program Work?

The nurse-led Maple Leaf PrEP Clinic is embedded in the Maple Leaf Medical Clinic, a multispecialty clinic providing health care in Toronto, and was opened in June 2018. The PrEP clinic has two exam rooms and a waiting room. Operating hours are Monday to Friday from 10:00 am to 6:00 pm.

Waiting room at the Maple Leaf PrEP Clinic

A clinic coordinator, who is also a registered nurse, coordinates the PrEP clinic. Clinic coordinator duties include performing outreach with organizations that could potentially refer clients to the clinic (e.g., sexual health clinics, HIV service organizations, community pharmacies, family doctors’ offices) to make them aware of the services provided and performing outreach and PrEP education for physicians who are interested in learning more about prescribing PrEP to their patients. The clinic coordinator also functions as the clinic nurse. Nursing duties include client intake/assessment, completion of initial and follow-up STI and other required tests (e.g., kidney function tests) and provision of PrEP prescriptions at three-month intervals under a medical directive.

Clients are connected to the clinic through community organizations (e.g., drop-in centres, HIV service organizations) and medical clinics or through self-referral by phone, email or walk-in. The clinic provides both daily and on-demand PrEP to clients (but not post-exposure prophylaxis). The clinic also works to make PrEP affordable through programs tailored to people lacking coverage through private insurance; for example, it links people to publicly funded programs (e.g., the Trillium Drug Program in Ontario). The clinic also informs people of other options, as appropriate (e.g., purchasing PrEP from outside of Canada).

The PrEP clinic operates through use of a medical directive that allows the clinic nurse to work with an expanded scope of practice, which includes managing the testing and treatment of STIs, testing for HIV, immunizing patients against human papillomavirus and hepatitis A and B and doing baseline and follow-up kidney function testing for PrEP patients.

When a client arrives at the clinic for the first time, there is an initial consultation with the clinic nurse. An intake form is completed, which includes a sexual history (e.g., use of condoms, past STI diagnosis) to determine HIV risk, in addition to an in-depth discussion about PrEP and sexual health. The clinic nurse discusses the risk assessment and, in very rare cases where the client’s risk profile is extremely low, may make a recommendation against PrEP. However, the vast majority of people who present for PrEP initiate it. During the initial consultation, blood and urine tests and swabs are completed to screen for HIV and other STIs, and tests are done to determine kidney function. An appointment is made with a clinic physician one to two weeks following the initial intake consultation.

Physicians review initial blood and urine test results and if any STI tests come back positive following the initial intake/assessment appointment, the client can return to the clinic and be treated by the clinic nurse prior to their initial appointment with a clinic physician. If the client is HIV negative, the clinic physician can issue the first prescription for three months of PrEP during their appointment with the client. After a prescription is initiated by a physician, it is renewed during quarterly follow-up appointments by the clinic nurse (working under medical directive). If the client is found to be HIV positive at intake, they are referred to an HIV physician on the same day to begin treatment.

Waiting room at the Maple Leaf PrEP Clinic

Clients return to the clinic one month after starting PrEP to meet with the clinic nurse and ensure that there are no issues (e.g., adherence issues, medication side effects, problems with cost). The visit normally includes an HIV and kidney function test, but not testing for all STIs unless clients indicate a need for testing. After the one-month check-in, follow-up appointments take place quarterly. At these appointments, clients check in with the nurse and receive adherence counselling, community resource referrals, sexual health counselling and blood/urine tests for STI screening and kidney function (i.e., creatinine). The clinic nurse and/or clinic physicians review tests. During these appointments, the clinic nurse provides PrEP prescriptions previously completed by the clinic physician.

If anything comes up between appointments (e.g., a suspected STI or suspected HIV infection, medication side effects), clients can book a same-day appointment with the clinic nurse.

An administrative staff person books appointments, does data entry, responds to email and phone inquiries, assists with ordering supplies and completing monthly budgets, coordinates meetings between providers and is usually the first point of contact for patients when they enter the clinic.