Prevention in Focus

Spring 2020 

Overcoming barriers to PrEP: Program models using diverse settings and providers

By Camille Arkell

It is well established that pre-exposure prophylaxis (PrEP) is a highly effective HIV prevention strategy.1 However, PrEP uptake has been relatively slow in Canada, partly because there have been limited ways for people to access it. When PrEP was first introduced it was prescribed mostly by doctors who have experience with HIV,2 but there are not enough of these doctors to meet the demand of providing PrEP to all people at high risk for HIV.2,3 Furthermore, PrEP can be delivered by a variety of healthcare providers in multiple settings, which offers choice and increases the likelihood of reaching diverse populations and communities that may not have easy access to HIV specialists. This article describes a selection of program models that decentralize PrEP delivery by using nurses and pharmacists working outside of the traditional doctor’s office. These program models engage a large and competent workforce and can help to overcome barriers to PrEP access (e.g., location, stigma, prescribing provider availability) and make PrEP available to a greater number of people.

Overcoming barriers to PrEP through innovative service delivery

Although the cost of PrEP has come down, and many provinces and territories now offer public insurance coverage for this medication, barriers to accessing PrEP remain. People may lack access to providers who prescribe PrEP for a variety of reasons: they may be uncomfortable talking about sexual practices in traditional health settings or they may not realize how high their HIV risk is,4,5 they may live in an area with few providers who prescribe PrEP,6 and many providers are unaware of PrEP or uncomfortable talking about sex with patients. 4,5

Different settings and providers can offer different ways of overcoming barriers to PrEP uptake experienced by people at high risk for HIV. PrEP delivery models may be more effective in settings that are easily accessible to people at high risk for HIV and/or when they include service providers who are comfortable discussing sex and drug use and have experience working with priority populations (e.g., gay, bisexual and other men who have sex with men [gbMSM]; people who inject drugs; people from countries where HIV is endemic). Some of the optimal settings for PrEP delivery have other services in place to more easily support PrEP care, such as on-site testing for sexually transmitted infections (STIs) or on-site PrEP dispensing.

Although the delivery model and type of provider can vary, care for people on PrEP is fairly standardized. The programs described in this article all deliver care according to either the Canadian PrEP guideline7 or the United States Centres for Disease Control and Prevention (CDC) PrEP guideline,8 which are very similar to each other and to other PrEP guidelines around the world.

Nurse-led models of PrEP delivery

Delivery of PrEP by nurses in established sexual health clinics is a popular model being used to increase access to PrEP. Nurses working within sexual health clinics are well positioned to provide PrEP services for many reasons, including:

  • their clinical training3
  • their familiarity with and comfort talking about sexual practices 4
  • the fact that they already provide regular STI testing for patients4
  • the potential cost savings compared with PrEP delivery by doctors4,9,10

Furthermore, many people who access sexual health clinics are prime candidates for PrEP because STI diagnoses are often used as an indicator that someone is at high risk for HIV.4,5 Sexual health clinics provide low-barrier services in a setting that people at high risk for HIV may prefer. A survey of gbMSM in Toronto found that two-thirds of respondents said they would prefer to seek PrEP from a nurse.11 Of 93 gbMSM who had a family doctor and were interested in taking PrEP, 66% said that they would prefer to seek PrEP from a nurse-led clinic rather than approach their doctor.10

Several examples of nurse-led PrEP in public health settings serve as successful models of how to build on existing capacity within the nursing workforce to deliver PrEP in an accessible, efficient and economical way, 2,4,10,12 both in Canada4 and internationally (e.g., Australia and the United Kingdom).10,12

Example of a nurse-led PrEP program

A well-documented example of nurse-led PrEP delivery is the PrEP-Registered Nurse or PrEP-RN program in Ottawa, Ontario. It is run entirely by nurses (registered nurses and nurse practitioners), from client assessment and initial PrEP prescription through to long-term follow-up. Through PrEP-RN, nurses working in public STI clinics are educated about PrEP and trained to follow step-by-step instructions on how to initiate PrEP and deliver ongoing follow-up, based on Canadian and CDC PrEP guidelines.4,5 A nurse practitioner writes the PrEP prescriptions but a medical directive allows trained registered nurses to provide PrEP to clients and to interpret laboratory results. This eliminates the need for a doctor to assess patients, review laboratory results or write prescriptions.

PrEP-RN started in August 2018, when STI clinic nurses began actively offering PrEP to people with HIV risk factors, regardless of their reason for visiting the clinic.5 Nurses identify patients who could benefit from PrEP using a risk assessment tool developed by the program, which includes information on sex and drug use practices, STI diagnoses and whether the client belongs to a group with elevated HIV prevalence.4,5 Nurses are prompted through the clinical record system to discuss PrEP with all clients who have HIV risk indicators such as an STI diagnosis or previous use of post-exposure prophylaxis (PEP).4,5 In addition, public health nurses who do STI case management also refer people to PrEP-RN when following up on STI diagnoses and notifying partners.5 The provider-initiated emphasis, which relies on a large network of providers, is a key part of this program because it aims to engage people at the highest risk of HIV, regardless of their perception of their own risk, rather than relying on people to ask for PrEP.4

At the initial PrEP visit, in addition to assessing a client’s suitability for PrEP and other health indicators (e.g., mental health), nurses assess how clients will pay for PrEP and help them to obtain coverage if necessary. The first prescription is for one month of PrEP. After a one-month check-in, clients are then given a new prescription every three months. Prescriptions are written by a nurse practitioner who writes a year’s worth of prescriptions after the initial visit and stores them in the client’s file.4

At every follow-up visit, a registered nurse completes a thorough assessment and conducts necessary laboratory tests before giving the client their next prescription. Conveniently, all specimens for laboratory testing are collected on-site, and nurses are provided with instruction and support to interpret the results of tests that they may not be familiar with, such as kidney function tests.4 Clients are followed at the PrEP-RN clinic for about six to 12 months before being linked to an external primary care provider to continue PrEP care. The external providers are given instructions on how to provide their client with ongoing PrEP care and also on how to initiate and prescribe PrEP, to increase their capacity to provide PrEP to others in their practice.

From August 2018 through August 2019, PrEP-RN identified 774 PrEP candidates and referred 377 to PrEP care.13 The remaining 397 people were either ineligible (already on PrEP, already HIV-positive, etc.), or declined because they did not feel sufficiently at risk for HIV or because they were concerned about taking PrEP.

There are other Canadian examples of collaborative models of PrEP delivery where nurses provide support related to PrEP care while doctors perform tasks such as clinical assessment, writing prescriptions and reviewing laboratory results.14,15,16 These collaborative models can be used to offer PrEP in creative ways in different contexts, such as more rural and remote settings where PrEP services are limited.

Pharmacist-led models of PrEP delivery

Pharmacists are another type of healthcare provider who are well positioned to deliver PrEP in a competent, convenient and accessible way.17 A pharmacist-led model of PrEP care may be beneficial for people who are not comfortable getting PrEP in traditional healthcare settings or in locations where PrEP access is limited. Pharmacists are experienced in drug therapy and in providing medication adherence counselling, and they are available in nearly every community, small or large. 17 Furthermore, PrEP drugs are available on-site at pharmacies; thus, prescriptions can conveniently be filled in the same place where care is delivered.

There is a Canadian PrEP guideline for pharmacists18 that highlights the role pharmacists can take in PrEP delivery. It suggests that pharmacists can be involved in the following roles:

  • screening clients for PrEP
  • providing PrEP education and risk reduction counselling
  • helping to initiate and follow up with people on PrEP
  • assisting with drug procurement and coverage
  • supporting adherence18

Programs in the United States have trained pharmacists to prescribe PrEP and monitor patients through collaborative practice agreements with HIV doctors. Similarly, a Canadian PrEP clinic run by a pharmacist and nurse team in Regina operates under a medical directive from an infectious disease specialist; 19 however, no information on outcomes for this program is currently available in the published literature.

Example of a pharmacy-based PrEP program

One-Step PrEP is a PrEP clinic located in a private pharmacy in Seattle, Washington, that is run by pharmacists who deliver PrEP care under the oversight of an HIV specialist doctor.20 The mechanism that allows this to happen is called a collaborative drug therapy agreement (CDTA). It permits the pharmacists to initiate and prescribe PrEP, order laboratory tests and monitor people on PrEP according to the CDC PrEP guideline. Pharmacists at this clinic are also able to offer testing and treatment for STIs, initiate post-exposure prophylaxis (PEP) and provide routine vaccinations as necessary.

The clinic developed a training program for pharmacists that includes training on PrEP guidelines, HIV and STI testing and treatment, how to take a sexual history and provide risk-reduction counselling, and how to provide PrEP medication counselling.20 The pharmacists at the clinic are given ongoing training to maintain their competency. They are trained in how to do blood draws for certain laboratory samples, and patient self-collection is used for other samples.

People are referred to One-Step PrEP by other healthcare providers and through a marketing campaign. A pharmacist conducts an initial hour-long consultation to obtain a medical and sexual history and provide all testing recommended by the CDC guidelines. If PrEP is indicated, the initial prescription is for one month of PrEP. Clients can have their prescriptions filled on-site or at a pharmacy of their choice. Clients return for follow-up after the first month on PrEP and every three months thereafter to receive routine testing and monitoring for adherence and side effects. Clients are referred to their primary care doctor or the medical director of the One-Step PrEP clinic for concerns outside of the pharmacists’ scope of practice under the CDTA. If clients do not have a primary care physician, they are required to obtain one within one year of starting the program. Over three years, from March 2015 to February 2018, 714 people were assessed for their suitability for PrEP and 695 (97%) started taking it.20 A very high percentage of people started PrEP on the same day as their initial appointment (74%), probably because PrEP medications can be dispensed on-site.

PrEP models to deliver care remotely

There are also examples of PrEP program models that provide aspects of PrEP care remotely,6,21,22 for example by using telemedicine, mailing PrEP medications to clients or offering remote laboratory testing. People at high risk for HIV may prefer to receive some or all components of PrEP services remotely or they may find it easier to access services delivered remotely for many reasons, including the following:

  • They may not feel comfortable going to a doctor’s office or clinic to get PrEP. 21
  • They may feel it takes too much time to attend in-person appointments for follow-up monitoring and laboratory work. 22
  • They may live in a rural or small urban area with limited access to PrEP providers. 6
  • They may live in a community with high levels of stigma surrounding HIV,6 or stigma around taking PrEP.21

These models may help to reach a greater number of people by offering remote PrEP services. We found no examples of remote PrEP programs in Canada in the published literature; however, several programs in the United States are documented in the literature.6,21,22

Example of a remote PrEP program

The Iowa TelePrEP program is a collaboration between five local public health departments in eastern Iowa serving a large geographic area of five urban and 16 rural counties.6 The model uses pharmacists to prescribe PrEP and provide follow-up care under a collaborative practice agreement with infectious disease doctors at the University of Iowa.

Sexual health clinics providing STI and HIV services in the local public health departments screen clients for PrEP indications and refer them to a TelePrEP navigator.6 Clients can also refer themselves online or by phone. A TelePrEP navigator contacts referred clients to provide PrEP education and help them apply for medication assistance programs and health insurance if needed. Navigators link people who are interested in taking PrEP to a TelePrEP pharmacist. Pharmacist appointments happen remotely using a videoconferencing application that can be downloaded to a client’s smartphone or other device.

After the initial video appointment, which includes a clinical assessment, the program mails PrEP medications to a client’s home or preferred address.6 Follow-up visits are conducted by video every three months and clients attend local laboratories for testing at baseline and every three months, according to the CDC PrEP guideline. Collaborations with local public health departments are crucial for arranging laboratory work and for ensuring rapid STI treatment when required.

The program received 186 referrals and pharmacists conducted 127 initial visits by video between February 2017 and October 2018.6 Three-quarters of clients who had an initial visit lived in small urban areas in the region, and 17% were from rural areas. The majority (91%) of clients were able to start PrEP within 7 days after their initial visit. This demonstrates that a telehealth PrEP program can reach people in areas with otherwise limited access to PrEP and can provide timely PrEP initiation even though it offers care remotely.

What lessons can we learn from these programs?

The main lesson is that PrEP can be delivered successfully by a variety of healthcare providers in a range of healthcare settings. Using diverse providers and settings is one way that programs can actively design their services to attract the most at-risk communities and keep them engaged in care. Sexual health clinics, pharmacies, community-based agencies, as well as traditional family practice settings can get creative in their PrEP delivery models, taking inspiration from those described above, to better accommodate people at high risk for HIV.

It is notable that the vast majority of PrEP delivery programs are currently targeting and serving gbMSM. Although this population has the highest rates of HIV in Canada (it is estimated 52% of people living with HIV in 2016 are gbMSM),23 other groups and individuals can benefit from the use of PrEP.5 An important part of the work to increase PrEP access must involve expanding access for diverse groups of people who may be at risk for HIV. This includes people who inject drugs and heterosexual people who have unprotected sex or use drugs in a population that has elevated HIV rates such as among African, Caribbean and black people and Indigenous people. Other factors such as recent incarceration and engagement in sex work may also put people at greater risk for HIV. It is important to consider all relevant factors when assessing risk for HIV and determining who to target for HIV prevention efforts in a given community.

Recommendations for service providers

As a service provider, you can link clients to innovative models of PrEP delivery happening in your community and can incorporate elements of these models into your own practice:

  • Provide education to your clients about PrEP and how it can be used to prevent HIV.
  • Conduct a scan of PrEP services and providers available in your community where you can link people who are at high risk for HIV and are interested in taking PrEP. Educate local doctors and nurses about PrEP, directing them to the Canadian PrEP guidelines or other clinical resources.
  • Look for partnership opportunities to deliver PrEP through collaborative and multidisciplinary program models in your area.
  • Support clients to talk to their doctors or other healthcare providers about getting on PrEP and encourage them to talk openly about their sexual and/or drug use practices. Offer your clients resources that they can bring to their providers to aid a conversation about PrEP.
  • Help your clients to figure out how they will pay for PrEP. They may need help to navigate public or private insurance coverage.

CATIE has created and compiled a number of resources on PrEP that can be used to educate clients, community members and potential PrEP providers.

Related article

For a discussion on PrEP programs with community members, see Views from the Frontlines: PrEP Programs.

References

  1. CATIE statement on the use of oral pre-exposure prophylaxis (PrEP) as a highly effective strategy to prevent the sexual transmission of HIV. Toronto: CATIE; 2019. Available from: https://www.catie.ca/en/prevention/statements/prep
  2. Sharma M, Chris A, Chan A, et al. Decentralizing the delivery of HIV pre-exposure prophylaxis (PrEP) through family physicians and sexual health clinic nurses: A dissemination and implementation study protocol. BMC Health Services Research. 2018;18:513-22.
  3. Nelson LE, McMahon JM, Leblanc NM, et al. Advancing the case for nurse practitioner-based models to accelerate scale-up of HIV pre-exposure prophylaxis. Journal of Clinical Nursing. 2019;28:351-61.
  4. O’Byrne P, MacPherson P, Orser L, et al. PrEP-RN : Clinical considerations and protocols for nurse-led PrEP. Journal of the Association of Nurses in AIDS Care. 2019;30(3):301-12.
  5. O’Byrne P, Orser L, Jacob JD, et al. Responding to critiques of the Canadian PrEP guidelines: Increasing equitable access through a nurse-led active-offer PrEP services. Canadian Journal of Human Sexuality. 2019;28(1):5-16.
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  7. Tan DHS, Hull MW, Yoong D, et al. Canadian guideline on HIV pre-exposure prophylaxis and nonoccupational postexposure prophylaxis. Canadian Medical Association Journal. 2017 Nov 27;189(47):E1448-E1458. Available from: http://www.cmaj.ca/content/189/47/E1448
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About the author(s)

Camille Arkell is CATIE’s manager, harm reduction, HIV prevention and testing. She has a Master of Public Health degree in Health Promotion from the University of Toronto, and has been working in HIV education and research since 2010.