Colorado, USA
2020

The same-day pre-exposure prophylaxis (PrEP) program in Colorado was implemented in a large urban sexually transmitted infection (STI) clinic. A variety of providers (e.g., nurse practitioners, pharmacists, patient navigators) assisted in assessing clients’ eligibility for PrEP, immediately initiated them on PrEP and linked them to follow-up PrEP care. PrEP assessment and laboratory testing were completed during clients’ visit to the STI clinic, where they could be prescribed a 30-day free trial of PrEP. Of the 100 people who participated in the program and were provided with a 30-day PrEP trial, 78% attended at least one follow-up appointment with a PrEP provider and 57% attended two or more follow-up appointments with a PrEP provider.

Program description

The same-day PrEP program was implemented in the largest STI clinic in Denver, Colorado. Adults aged 18 years and over who met the US Centers for Disease Control and Prevention’s PrEP criteria¹ and who were able to attend follow-up appointments were eligible to participate in the program. A nurse practitioner, or a registered nurse working with physician oversight, evaluated a client’s PrEP eligibility for and interest in starting same-day PrEP.

Interested individuals had the following tests during their visit to the STI clinic:

• serum creatinine test
• hepatitis B surface antigen test
• urine pregnancy test
• a point-of-care HIV antigen/antibody test

Individuals were also assessed for a history of hepatitis B or renal disease and for signs of acute HIV infection. HIV and pregnancy test results were reviewed during the visit and participants were contacted within two days if any of the remaining tests came back with abnormal results.

A pharmacist, who counselled participants on PrEP adherence and potential side effects of the medication, provided individuals with a free 30-day PrEP prescription. During this visit, a patient navigator provided education and assessed the client’s finances and insurance status. An insurance enrollment specialist worked with participants who did not have insurance to find ways to cover the costs of their subsequent PrEP prescriptions.

After the initial visit to the STI clinic, clients who received the PrEP starter pack were linked to follow-up care at participating clinics including primary care clinics, infectious disease clinics and internal medicine clinics.

The patient navigator scheduled a one-month follow-up appointment for clients at the clinic they were referred to and called clients one week after they started PrEP to assess side effects. A physician addressed any clinical questions the client had, and the patient navigator was available until the one-month follow-up appointment to help the client navigate healthcare services or deal with insurance issues. If clients were interested in PrEP but not in same-day PreP, a standardized referral to an outside clinic was made.

Results

The study took place between April 2017 and October 2018. A total of 131 clients were screened for enrollment in the study; 100 clients were enrolled in the study. Of those enrolled in the study, 98% were men who have sex with men and 50% had had a recent syphilis, chlamydia or gonorrhea infection.

All participants had a financial assessment and 65% were linked to at least one financial assistance program. The patient navigator linked 55% of participants to a primary care clinic for follow-up and 45% to an infectious disease clinic for follow-up.

The study found that:

• 78% of participants attended at least one follow-up with a PrEP provider
• 57% attended two or more follow-up appointments with a PrEP provider

In a multivariate analysis of characteristics associated with attending at least one follow-up PrEP appointment, higher annual income was the only statistically significant characteristic associated with attending follow-up appointments (each $10,000 increase in income was associated with a 1.7 times greater odds of attending at least one follow-up PrEP appointment). Other characteristics considered included reported health insurance status coverage at enrollment, having a primary care provider and race/ethnicity.

In a client satisfaction survey completed by 54% of participants, 96% reported that they planned to continue taking PrEP and 100% reported that they liked having access to same-day PrEP. A qualitative analysis also found that participants said that the program was convenient and easy to use and that it removed barriers to accessing PrEP.

What does this mean for service providers?

Same-day initiation of PrEP is feasible in an STI clinic setting. Use of a patient navigator to facilitate access to a one-month PrEP follow-up appointment and insurance coverage for PrEP probably contributed to the high rate of follow-up with a PrEP provider. All participants reported that they liked having access to same-day PrEP.

Service providers should consider ways to offer same-day PrEP in their programs, while also considering the factors that may contribute to a client’s ability to complete follow-up care for PrEP (e.g., real and perceived costs associated with PrEP). Use of a multidisciplinary team (e.g., nurses, patient navigators, physicians) may also help to facilitate access to PrEP.

Related resources

The Maple Leaf PrEP Clinic – case study

Text Message Reminders – program element

Reference

Kamis KF, Marx GE, Scott KA et al. Same-day HIV pre-exposure prophylaxis (PrEP) initiation during drop-in sexually transmitted diseases clinic appointments is a highly acceptable, feasible, and safe model that engages individuals at risk for HIV into PrEP care. Open Forum Infectious Diseases. 2019;6(7):ofz310.

1. US Public Health Service. Pre-exposure Prophylaxis for the Prevention of HIV Infection in the United State – 2017 Update. A Clinical Practice Guideline. Atlanta: US Centers for Disease Control and Prevention; 2018. p. 13. Available from: https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prep-guidelines-2017.pdf.

2019

Integrating hepatitis C care into an overdose prevention service

The Moss Park Consumption and Treatment Service (MPCTS) first opened in August 2017 in the east end of downtown Toronto. MPCTS provides supervised injection and consumption services, distributes harm reduction supplies and offers other drug-user health services. MPCTS currently serves over 100 people a day.

In 2019, MPCTS launched an integrated hepatitis C testing and treatment program. The hepatitis C program was implemented to reach people who use MPCTS services (referred to as members) and face barriers to accessing traditional healthcare. It aims to increase uptake of testing and treatment services in a low-threshold, safe environment and to decrease loss to follow-up by reaching members who regularly access services at MPCTS.

The front entrance of Moss Park CTS with a sign for the hepatitis C program.

Why integrate hepatitis C treatment into a supervised consumption service?

MPCTS developed the program in response to service users asking for more support for hepatitis C testing and treatment. Some had already been diagnosed with hepatitis C and had been referred to a nearby community program that provides hepatitis C treatment. However, a number felt uncomfortable accessing care at a health centre, some due to negative past experiences with care providers  (e.g., stigma experienced in health care settings as a person who uses drugs). Past negative experiences with healthcare providers/systems are a major barrier to hepatitis C care. Members also gave feedback that the structure and scheduling of other hepatitis C programs was a barrier.

MPCTS developed the hepatitis C program with a low-barrier approach to meet the needs of people who use drugs. Before the program was implemented, individuals often had to attend several separate appointments at multiple agencies to receive medical assessments, obtain identification documents, apply for insurance coverage and then receive ongoing monitoring and support. The MPCTS hepatitis C program enables members to obtain all of these services in one place. The program was also developed to address the lack of community-level prescribers and the lack of programs who will work with people who use drugs in a stigma- and judgment-free environment.

The entrance and intake area at Moss Park CTS.

How does the program work?

A treatment nurse from the Toronto Community Hepatitis C Program, a community-based treatment program, comes to MPCTS each week for a three-hour clinic. During these visits, this nurse works alongside other nurses, overdose prevention workers and community health workers, many of whom have lived experience.

During clinic hours, the visiting hepatitis C nurse performs testing and checks in with existing patients on treatment within a converted clinical space at MPCTS. Hepatitis C testing is done using a standard antibody test for hepatitis C, followed by an RNA viral load test if the antibody test is positive. The nurse draws blood on-site at MPCTS for both of these tests; the blood is taken to a nearby health centre for processing and delivery to the testing laboratory. Other clinical services, including wound care, testing for sexually transmitted and blood-borne infections, and referrals are also available during clinic hours. Once hepatitis C test results are available, they are communicated to members at subsequent nurse visits. If this is the first time a member has tested positive for hepatitis C, arrangements are made for a re-test 6 months after the initial blood draw. This re-test is a requirement for publicly covered treatment in Ontario.

Members who are ready to engage in hepatitis C treatment are offered two options: they can be referred to the Toronto Community Hepatitis C Program group program at a nearby community health centre, or they can receive treatment on-site at MPCTS. Baseline blood work is done and blood marker indicators of liver fibrosis are tested before treatment.

For on-site hepatitis C treatment, members receive a medical assessment and prescriptions during an on-site appointment with a prescriber. Members choose the method of medication dispensing that works best for them (daily or weekly dispensing at a pharmacy, or daily or weekly dispensing at MPCTS). MPCTS staff and the treatment nurse check in with people on treatment at least once a week, primarily in-person when members access the site. Any monitoring or follow-up blood tests, including for liver fibrosis, are performed on-site.

MPCTS implemented the program without any additional funding and so relied heavily on existing resources. For members who receive their medications at MPCTS, community pharmacies dispense the medications to MPCTS nurses who oversee daily or weekly distribution of hepatitis C treatment to members. The MPCTS staff also provide counselling and peer support for members before and during treatment. Because many members are regular visitors to MPCTS, staff have developed supportive relationships with them. They are able to easily follow up and identify any needs or barriers during testing or treatment, actively engage in case management and get advice from the hepatitis C nurse on how to manage issues.

A significant piece of work was setting up computers to enable workers to access medical records, order and print laboratory tests and write prescriptions on-site. The computer software and network linkages were important in supporting comprehensive clinical services on-site.

The consumption room at Moss Park CTS.

What are the accomplishments and future directions?

In the first six months, 32 people engaged in testing through the MPCTS hepatitis C program. By using MPCTS as a meeting place, all but one of the 32 people tested received their test results. Toronto Community Hepatitis C Program staff were initially concerned it would be difficult to follow up with MPCTS members, many of whom do not have fixed addresses or phone numbers. However, the membership of MPCTS is relatively constant, and follow-up has been effective because members tend to visit the site regularly and staff work to maintain supportive relationships.

Of those members who completed blood tests, 13 tested positive for hepatitis C. Since June 2019, a prescriber has been on-site and able to initiate treatment for five people, with two others waiting for follow-up testing to confirm that they have a chronic infection. A number of other members have expressed interest in beginning treatment and are in various stages of treatment work-up.

In the future, the program is looking to expand the peer mentorship and health navigation aspect of the program. This may include an element where MPCTS members who have completed treatment can engage and support other members who are receiving hepatitis C care and assist them in seeking any health services they may need that are not related to their hepatitis C care.

MPCTS is also looking to expand testing services on-site, including implementing RNA point-of-care testing in a research capacity. This would enable the program to offer members more rapid diagnosis of hepatitis C and initiation of treatment. Additional testing, such as HIV point-of-care testing, will also be performed on-site.

Given the tight network of frequent service users at supervised consumption services, a community-based model of care in this setting has been effective. According to the hepatitis C treatment nurse, “the keys to success have been leveraging the existing strength of community connections and resources, and following the feedback from members to develop and roll out this service.”

Contact Information

Bernadette Lettner
Hepatitis C Treatment Nurse, Toronto Community Hepatitis C Program
blettner@srchc.com
416-302-5675