What is the Program?
The HIV Prevention Clinic is a comprehensive, inter-professional HIV prevention service housed in the Immunodeficiency Clinic at the Toronto General Hospital (TGH) in Toronto, Ontario. The Immunodeficiency Clinic specializes in HIV care and hosts the HIV Prevention Clinic.
This clinic provides:
- occupational and non-occupational post-exposure prophylaxis (PEP) to people who have been exposed to HIV
- pre-exposure prophylaxis (PrEP) to people who are at ongoing high-risk for HIV acquisition
- ongoing mental health support and counselling, and linkage to other community resources, for those who visit the clinic to access PEP or PrEP
- care for individuals not on PrEP, but considering PrEP to help them remain HIV negative
- support for direct transition into HIV care for those who test HIV positive
The HIV Prevention Clinic provides services to people at high risk for HIV, regardless of age, race, sex, or HIV risk activities.
Why Was the Program Developed?
In late 2011, before the HIV Prevention Clinic opened, some leaders in HIV care in Toronto recognized that a clinic that provides comprehensive HIV prevention services, including the provision of PEP and PrEP, could play a major role in helping to address both new HIV infections and an unmet need for new biomedical HIV prevention services in Toronto.
The Immunodeficiency Clinic at Toronto General Hospital (TGH) was well-positioned to meet the need for biomedical HIV prevention services. TGH is located in an area of the city that is home to many people at high risk for HIV infection. Although the Immunodeficiency Clinic previously played a limited role in HIV prevention, it did have extensive experience providing high-quality, non-judgemental care for people living with HIV and was well set up to add prevention to its range of services.
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 specialty 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.
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.
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.
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.
- Nurses. Provide information, advice, and counselling related to sexual health, including PrEP and PEP; and perform screening for various health conditions (e.g., hepatitis C and other STIs).
- Social workers. Provide psychosocial support, counselling services, and significant support identifying financial coverage for PrEP and PEP; and outreach to and maintain connections with referral clinics.
- Psychiatrist. Provides psychosocial support and counselling as needed.
- HIV physician. Provides information, advice, and counselling related to sexual health, including PrEP and PEP; assesses clients for PrEP eligibility and prescribes treatment; monitors physical and mental health through clinical assessments; performs screening for various health conditions (e.g., hepatitis C and other STIs); and provides treatment or refers to another provider for treatment/monitoring.
- Pharmacist. Distributes medications prescribed by the HIV physician; provides information to clients about the medications and their use; and advises physician on the selection, dosage, interactions, and side effects of medications.
- Reaching all those who could benefit from PEP or PrEP: The staff at the HIV Prevention Clinic believes that they are reaching only a small percentage of people in Toronto who could benefit from their holistic HIV prevention services. Reaching all people who need these services and increasing their knowledge of how these services can help them stay healthy or improve their health is a challenge. One proposed solution is to support PEP and PrEP provision in community settings by public health or primary care providers. Staff at the HIV Prevention Clinic conduct education sessions to train other healthcare providers to conduct HIV prevention care as a way to improve access to these services.
- Knowledge about PrEP among primary care providers: There is a lack of knowledge among primary care providers about PrEP. This makes it challenging for clients to access PrEP. It also creates a challenge for the HIV Prevention Clinic to reach out to all primary care providers who are unaware of the benefits of PrEP and how to prescribe it.
- Cost of PrEP: It can be a challenge for clients to pay for PrEP. However, Health Canada approved PrEP in 2016. Each province and territory will now assess it for inclusion on public drug plans.
The clinic assesses its success in a number of ways. Staff track clients who access PEP and complete the full course of the medication; how many clients transition successfully to PrEP among all those eligible; and how many clients access PrEP, remain engaged, and remain HIV negative.
As of February 2016, no PEP or PrEP clients have seroconverted. Two clients presented to the clinic to access PrEP with an acute HIV infection. Their infection was identified before they started PrEP. This highlights the importance of verifying a client’s HIV-negative status before PrEP initiation.
The HIV Prevention Clinic also carried out a retrospective review to assess how well they were engaging with, and retaining, PrEP clients. This was done over a two-year period by performing client chart reviews.
Over the course of two years:
- 64 clients had an initial intake visit for PrEP
- 45 (70%) initiated PrEP
- 39 (87%) clients had complete adherence to follow-up visits (only six clients missed one clinic visit and no one missed more than one)
Evaluations have demonstrated the importance of STI screening and treatment in PrEP care. Eighteen percent of clinic clients have been diagnosed with a bacterial STI during follow-up. Evaluations have also demonstrated the importance of the sexual health counselling provided by the program. No new cases of HIV have been identified in PrEP clients at the clinic.
- Providers need to understand PrEP. Education to providers and communities on the existence and benefits of PrEP is critical to increasing the uptake of PrEP in Toronto and in Canada.
- There are many benefits to engaging in a holistic biomedical HIV prevention program. A holistic PEP and PrEP program can have significant positive outcomes for non-HIV issues among clients. Screening for other health conditions (e.g., hepatitis C and other STIs), addressing broad health issues, and providing ongoing mental health supports to clients can improve their general wellness.
- Co-located staff and services reduce barriers to access and engagement. Clients can access a number of experts in one clinic, all of whom are knowledgeable about PEP and PrEP. This makes access easier and ensures that clients do not have to discuss their reasons for accessing PEP or PrEP with different providers in different clinics.
- Providing support around financial coverage of PEP and PrEP is crucial. The HIV Prevention Clinic social workers have extensive knowledge of private and public insurance plans/systems, which can support quick and easy access to PrEP for clients who cannot pay for it on their own.
Other Useful Materials
Information found on the CATIE website
- Information on post-exposure prophylaxis (PEP) for prevention
- Information on pre-exposure prophylaxis (PrEP) for prevention
HIV Prevention Clinic