Uganda
2020

An HIV self-testing program in Uganda trained men who have sex with men (MSM) to distribute HIV self-tests to their social and sexual networks. The program included training on how to use the HI­­V self-test, counsel people who take the test, and link people who tested positive to HIV confirmatory testing and HIV treatment. The study found that the distribution of HIV self-tests by peers identified significantly more undiagnosed HIV cases than standard testing (5.6% vs. 2.7%) and reached more never testers and MSM who had not tested in the past six months. 

Program description

Fifteen MSM (i.e., peers) were trained in HIV self-testing procedures, including result interpretation for the OraQuick HIV test. Additionally, peers received training on the following topics:

• how to troubleshoot situations that may arise during the testing process
• how to counsel people who take the test
• confirmatory testing
• how to address any misunderstandings related to testing results
• how to link people to HIV services

Each HIV self-testing kit contained images of how to use the self-test, information on wait times for results following the test and guidance on how to interpret test results. Following the training, peers were asked to use the self-test using the instructions provided, to demonstrate that they understood the procedures.

After signing a confidentiality agreement, peers were provided with 10 HIV self-testing kits to distribute to people in their social and sexual networks. The program targeted MSM who had not tested for HIV in the previous six months.

Peers provided self-test kits to participants; however, participants were not required to test in the presence of a peer nor to disclose the results of the test to the peer. Participants who received a kit were contacted by phone or were met at testing locations one to two weeks after kit distribution to see if they had used the kit. If a person declined the HIV self-test, they were invited to discuss the reasons for their decision. 

If participants shared their tests results with the peer and the result was positive, they were linked to a local organization for confirmatory testing. If the result of the confirmatory HIV testing was positive, participants were linked to HIV services. Peers could also escort participants to confirmatory testing and HIV services if the participants disclosed their tests results to them.

The peer-distributed self-testing approach was compared with the standard of care, or “moonlight testing approach,” which involved HIV testing in the evening at MSM “hot spots” using conventional HIV testing methods.

Results

Peers distributed 150 HIV self-testing kits and 95% of the people who received a kit (143) completed an HIV self-test.

• 94% of participants were counselled (after testing) by the peer who had given them the kit or a peer at the affiliated health facility
• 61% of participants tested alone
• 39% of participants tested with the support of or presence of a peer
• 32% had never previously tested for HIV

Eight participants (5.6%) tested positive with the HIV self-test. All eight disclosed their test results to the peers and all eight were linked to care where they received confirmatory testing and initiated antiretroviral therapy.

For comparison, 147 MSM participated in the standard of care testing approach during the study period, and four previously undiagnosed HIV infections were found. A comparison of the HIV self-test and standard of care groups found a statistically significant difference in the number of MSM who tested positive for HIV in each group (5.6% and 2.7%, respectively).

What does this mean for service providers?

This study shows that the distribution of HIV self-tests is feasible and accepted by testers. These findings are similar to those of comparable studies conducted in the United Kingdom and the United States. Service providers could consider innovative ways to use HIV self-tests if they are approved for use in Canada. This can include not only ways to have peers support the distribution of HIV self-tests but also ways that peers might support the use of the self-tests and roles that peers can play in linking people who test positive to confirmatory testing and HIV treatment services.

Related resources

Task-shifting in HIV testing services

Rapid point-of-care HIV testing: A review of the evidence

Peer HIV testing

Reference

Okoboi S, Lazarus O, Castelnuovo B et al. Peer distribution of HIV self-test kits to men who have sex with men to identify undiagnosed HIV infection in Uganda: a pilot study. PLoS ONE. 2020;15(1):e0227741.

Virginia, USA
2019

With the advent of direct-acting antivirals (DAAs), hepatitis C treatment is more widely available than in the past, although linking patients to care remains challenging. This study looked at the use of a nurse navigator who provided support to link patients to hepatitis C treatment at an infectious diseases clinic. The focus of the study was linkage to care, although the study also looked at engagement across each step of the cascade or care (e.g., treatment initiation, follow-up testing). The study found that the nurse navigator was effective at engaging people in care: 76% of patients who were referred to the clinic went on to be linked to care. Even though this represents a high rate of linkage, this step remained the point in the cascade of care at which people were most likely to drop out of care.

Program description

The University of Virginia (UVA) Infectious Diseases Hepatitis C Clinic is part of the UVA hospital system. Referrals to the clinic come from other parts of the UVA hospital system, community service providers or the local health department. The clinic is staffed by a full-time nurse navigator who does linkage to care, physicians and a pharmacy-based team.

When patients are referred to the clinic, the nurse navigator contacts them by phone or letter to schedule an appointment. The nurse makes multiple attempts to reach a patient and reschedules appointments as needed. The nurse navigator also provides education and counselling over the phone and at in-person appointments.

During the appointment, the nurse ensures that any necessary paperwork for insurance coverage or patient assistance programs is complete, so that the patient is able to gain timely access to medications. Once the patient begins treatment, a pharmacy-based team is also available to provide telephone-based counselling related to the patient’s medications. If patients are lost to follow-up, the nurse continues to attempt to contact them.

Results

This observational study took place from 2014 to 2018 and focused on rates of linkage to care. Linkage to care was defined as attendance at one hepatitis C clinic appointment. The nurse navigator also collected other information about the patient’s progression through the cascade of care from referral to cure.  The cascade of care phases were as follows:

1. Referral to the clinic
2. Linkage to care (attending an appointment)
3. Medication prescribed
4. Patient beginning treatment
5. Patient completing treatment
6. Post-treatment testing for hepatitis C
7. Cure or sustained virologic response (SVR)

The nurse recorded reasons for patient drop-off at any point of the cascade.

Overall, 824 patients were included in this study and 76% (624) were successfully linked to care (i.e., attended at least one appointment). Additionally:

• 61% (502) began treatment,
• 57% (471) completed treatment

Retention of patients at each step of the cascade is depicted below.

The greatest drop-off was seen in the linkage-to-care phase. The most common reasons for failure to link to care were patients not attending a scheduled appointment, inability to contact a referred patient in the first place or drop-off because of incarceration.

However, despite this drop-off, the overall rate of linkage to care was comparable to or higher than the rates reported in other studies (e.g., surveillance data reported a 17% linkage to care rate in the USA in 2016). The success of this program in linking patients to care was attributed to the use of a full-time nurse navigator who was able to actively engage patients.

What does this mean for service providers?

This study shows that use of a nurse navigator can be an effective way to support patients through the cascade of care in a clinical setting. When additional efforts are made to engage people, linkage to care tends to improve, and subsequently the rates of treatment and cure improve too. Although the biggest drop-off in the study was during linkage to care, patients who did attend appointments generally went on to begin and complete treatment. With new DAA therapies, treatment is a relatively easy process. The major hurdle now is getting people engaged in care in the first place.

Related resources

Patient Navigation - Evidence Brief

Think link: Programmatic approaches for successful linkage to HIV care - Evidence Review

Check Hep C – Evidence Brief

HepTLC – Evidence Brief

References

Sherbuk J, McManus K, Knick T et al. Disparities in hepatitis C linkage to care in the direct acting antiviral era: Findings from a referral clinic with an embedded nurse navigator model. Frontiers in Public Health. 2019;7:362.

Mississippi, USA
2020

The pharmacist-led, same-day, pre-exposure prophylaxis (PrEP) program in Mississippi was created to address high drop-off rates seen during referral to PrEP. The program targeted those at high risk for HIV, connecting clients with a pharmacist located in the same building as a testing centre for HIV and sexually transmitted infections (STIs). Through a collaborative practice agreement, the program pharmacist could prescribe PrEP outside of a clinical setting and on the same day that clients visited the centre for their initial testing. Baseline PrEP testing (e.g., serum creatinine) was completed during a follow-up clinical appointment with a clinical provider within six weeks. The program was able to provide an initial prescription to all clients who were connected to a pharmacist. Among this high-risk group, 33% of clients who were provided with a prescription went on to attend their first clinical appointment within six weeks.

Program description

Clients who attended a walk-in HIV/STI testing centre staffed by two nurses were offered same-day PrEP if they tested negative for HIV through a rapid point-of-care test. Additionally, PrEP was explicitly recommended to those who tested negative for HIV on a rapid point-of-care test and were:

• men who reported having sex with men
• transgender women
• cisgender women who were diagnosed with an STI, who had contact with a partner with HIV or an STI, who had an ongoing sexual relationship with an HIV-positive partner or a partner whose HIV status was unknown, who reported recent injection drug use, or who had an ongoing sexual relationship with men who have sex with men

Clients who were interested in PrEP were connected with the on-site pharmacist or were contacted by the pharmacist within 48 hours if they couldn’t meet that day. During the initial meeting, the pharmacist:

• provided clients with information about the effectiveness and side effects of PrEP as well as the importance of adherence
• took clients’ medical history, including contradictions for PrEP (e.g., kidney disease)
• assessed clients for acute HIV (those showing signs of an acute HIV infection were referred on the same day to a specialist for post-exposure prophylaxis)
• completed paperwork for insurance coverage

For clients who were not showing signs of acute HIV infection and who did not have contraindications for PrEP, a 60-day PrEP prescription was sent to the client’s preferred pharmacy. A collaborative practice agreement allowed the program’s pharmacist to work in partnership with a physician within a defined role: the pharmacist was able to assume responsibility for tasks such as doing assessments, providing referrals, administering medications and prescribing PrEP (prescriptions were billed under a physician’s name). Laboratory tests were not completed during the initial meeting; the pharmacist scheduled an appointment for follow-up within six weeks with a clinical provider, who would complete the client’s baseline PrEP testing (e.g., serum creatinine). If clients did not pick up their initial prescription, the program pharmacist contacted them weekly for one month. Prescriptions were not refilled if the client did not attend their six-week clinical appointment.

Patients with signs of acute HIV infection or contraindications for PrEP were referred the same day to an infectious disease doctor for evaluation.

Results

This observational study took place between November 2018 and May 2019. A total of 69 clients were referred to the program’s pharmacist for same-day PrEP. All of these clients received a prescription for PrEP. Results show that:

• 90% of clients (62) were seen by the pharmacist on the same day as they had their HIV test
• 83% of clients (57) received a PrEP prescription on the same day that they tested HIV-negative
• 77% of clients (53) filled their PrEP prescription  
• 43% of clients (23/53) who filled their prescription attended a clinical appointment within six weeks

Therefore, 33% (23/69) of those who were referred to the same-day PrEP program filled a PrEP prescription and were linked to PrEP care.

What does this mean for service providers?

Although this study had a small number of participants (69), it focused on people at high risk for HIV and tried to address  some of the challenges associated with the drop-offs normally seen with PrEP referrals. The program was able to prescribe PrEP to all participants, although only 33% of those who were prescribed PrEP attended a clinical appointment for a baseline assessment. Therefore, this approach also highlights the importance of finding ways to retain clients in programs in addition to initiating their use of PrEP.

This study was unique in that it allowed people to start PrEP outside of the clinical setting. This program shows that it is possible to initiate PrEP outside of clinical settings and that pharmacists can play a role in facilitating the process of initiating PrEP.

Related resources

The Maple Leaf PrEP Clinic – Case Study

Text Message Reminders – Program Element

References

Khosropur CM, Backus KV, Means AR et al. A pharmacist-led, same-day, HIV pre-exposure prophylaxis initiation program to increase PrEP uptake and decrease time to PrEP initiation. AIDS Patient Care and STDs. 2020;34(1):1-6.

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.