What is the program?
The nurse-led drop-in program (Prism Wellness and Testing Night) at the Cool Aid Community Health Centre (Cool Aid CHC) provides clinical drop-in services including testing for sexually transmitted and blood-borne infections (STBBIs), treatment and education. The program also offers access to STBBI prevention approaches including pre-exposure prophylaxis (PrEP) to prevent HIV and doxycycline post-exposure prophylaxis (doxyPEP) to prevent bacterial sexually transmitted infections (STIs) (e.g., syphilis, chlamydia).
The Victoria Cool Aid Society (VCAS) offers services to adults who are impacted by poverty, colonization, mental health and/or substance use challenges, and stigma and those experiencing homelessness. Services include permanent and transitional housing programs, emergency shelters, health and dental care, employment assistance, and social and recreational opportunities. The Cool Aid CHC is a division of the VCAS and offers lower barrier healthcare at a medical clinic that includes primary care services, mobile health clinics (e.g., outreach to supportive housing sites, to shelters and on the streets), pharmacy services, a nurse-led hepatitis C treatment program and the nurse-led STBBI drop-in program.
Why was the program developed?
The nurse-led drop-in program was developed to reduce barriers to care and improve access to STBBI services for people who often face stigma and discrimination in traditional healthcare settings. By offering clinical services without appointments in a safe and supportive environment, the program aims to provide more equitable access to care with the goal of increasing education and reducing STBBI incidence in the communities that it serves.
Building on the Cool Aid CHC’s long-standing commitment to offering outreach and testing services in community-based settings (e.g., local parks, on-site sex establishments, brothels), the program started in 2014 by offering a twice-monthly men’s STBBI testing night for gay, bisexual and other men who have sex with men (gbMSM) who were experiencing challenges accessing sexual health services. In response to emerging research, trends and evolving community needs, the program expanded to reach people of all genders and sexual orientations.
How does the program work?
The nurse-led drop-in program operates out of the Cool Aid CHC in partnership with AIDS Vancouver Island (AVI) Health and Community Services’ Prism Wellness program. It is a one-stop-shop for STBBI testing, treatment, education and access to STBBI prevention approaches (e.g., HIV PrEP, doxyPEP).
The program is led by registered nurses with STI certified practice (RN(c)) and supported by a health promotion educator for Prism Wellness. RN(c) can order diagnostic tests and can diagnose and prescribe STI treatment on the basis of certified practice decision support tools.
The Prism Wellness and Testing Night runs weekly on Thursdays from 5:30 to 7:30 p.m. and is open to people of all genders and sexual orientations. The program is advertised on social media by the health promotion educator for Prism Wellness and through word of mouth by clients.
When a person enters the clinic, medical office assistants greet them and add their name to a list to be seen by the nurses. While people are waiting, the health promotion educator for Prism Wellness can chat with them and provide education through discussion or resources (e.g., pamphlets). People are seen on a first-come, first-served basis.
Nurses meet privately with each person and provide them with the information they need to make informed decisions about their sexual health. Nurses use a conversational approach to learn more about the types of sex that people are having (e.g., what parts of the body require testing), assess any symptoms or concerns and answer questions. In their conversations with clients, nurses use a trauma-informed approach (e.g., they inform people why they are asking questions) and they respond to the level of comfort that clients have with nurses and the clinic. Nurses strive to be non-judgmental, using a gentle and supportive approach to conversations.
The following services are available through the nurse-led drop-in program:
- sexual health education including STBBI prevention methods
- STBBI testing that is geared to an individual’s behaviours and preferences
- treatment for STBBIs
- HIV PrEP eligibility assessment and follow-up care
- doxyPEP eligibility assessment and follow-up care
STBBI education
During one-on-one meetings, nurses can provide education and information on safe sex (e.g., condom use), STBBIs, HIV PrEP and doxyPEP. They can also share information on STBBI testing and treatment and provide pre-test HIV counselling as needed. Nurses answer any questions or address any concerns that clients might have.
STBBI testing and vaccines
On the basis of what is discussed during the one-on-one meeting, nurses assess clients’ risk and recommend relevant STBBI testing. STBBI tests are done on-site and sent to a laboratory for processing. Potential testing modalities include phlebotomy to check for blood-borne STBBIs and for immunity against hepatitis A and B, rapid point-of-care HIV tests, swabs and urine specimens for bacterial STI infections, and human papillomavirus (HPV) swabs for clients with a cervix. Clients who have not received vaccines for hepatitis A, hepatitis B or HPV are offered immunization.
STBBI testing is completed by nurses and clients. For example, nurses perform phlebotomy and offer throat swabs, and clients are given the choice of doing their own rectal and/or vaginal self swabs. Test results are communicated back to the Cool Aid CHC and clients can also look up their results online through a secure portal. The clinic uses a “no news is good news” policy for test results and follows up with clients only if test results are positive.
STBBI treatment
If test results are positive, clients are notified by a nurse and can return to the Cool Aid CHC for treatment during the nurse-led drop-in or during regular clinic hours by booking an appointment. If a person tests positive for HIV and does not have a primary care provider, nurses will connect them to a primary care at the Cool Aid CHC for ongoing HIV care and primary care. If a person tests positive for hepatitis C they are referred to the hepatitis C nurse coordinator at the Cool Aid CHC, who can assist them with getting connected to treatment and care.
If a client attends the nurse-led drop-in program and shares that they have been in contact with someone with an STI or that they have symptoms of an STI, they may be tested and treated during a single visit if clinically indicated.
Accessing HIV PrEP and doxyPEP
During the clinic visit, the nurse will recommend PrEP and/or doxyPEP on the basis of their assessment of the client’s risk for HIV, chlamydia and syphilis. Eligibility for the provincial HIV PrEP and doxyPEP programs is determined centrally by the BC Centre for Excellence in HIV/AIDS (BC-CfE HIV), which also coordinates the programs and dispenses the medication. The enrolment for these programs includes blood work, STI screening and completion of the program enrolment forms. The BC-CfE also requires completion of the HIV Incidence Risk Index for Men who Have Sex with Men (HIRI-MSM index) for HIV PrEP eligibility, a screening tool used to identify gbMSM with a high risk of HIV acquisition.
For HIV PrEP, once the test results are reviewed and the paperwork is complete, the enrolment form is faxed to the BC-CfE HIV. When the PrEP prescription is approved, PrEP medications are sent to the Cool Aid on-site pharmacy approximately 10 days after the initial visit. In rare circumstances, the medication can be sent to a different pharmacy. When clients have 14 tablets left, they are asked to return to the drop-in for another PrEP prescription, a follow-up HIV test and the required monitoring (e.g., kidney function test).
To be eligible for the doxyPEP program, individuals must either be enrolled in the HIV PrEP program or be living with HIV and must have had STI screening conducted in the last 12 months. A similar process is followed for enrolment: forms are completed during the drop-in visit and faxed to the BC-CfE HIV. If approved, doxyPEP medications are sent to the Cool Aid pharmacy for clients to pick up — typically a 30-tablet supply (15 doses) to start.
Required resources
- Nurses with STI certified practice
- A health promotion educator to greet clients and provide sexual health education
- Welcoming clinical space with private clinic rooms and a waiting room
- STBBI testing supplies
- Central laboratory to process test results
Evaluation
The nurse-led drop-in program’s Prism Wellness and Testing Night regularly sees 10–14 people each week for STBBI education, testing and treatment, averaging over 40 visits per month. From the launch of BC-CfE’s HIV PrEP Program in December 2018 to December 2024, a total of 353 people were enrolled through the nurse-led drop-in program. Overall, 158 (45%) of those who started on HIV PrEP in 2018–24 have continued on PrEP.
Between December 27, 2022, and December 31, 2024, a total of 186 individuals received doxyPEP to use within 72 hours of unprotected sexual contact, including 177 people who identified as gbMSM and 19 people living with HIV.
Challenges
- Accessing HIV PrEP and doxyPEP through the BC-CfE HIV requires a significant amount of nursing time.
- The nurse-led drop-in sees many clients and workflow can become challenging.
- There is an ongoing nursing shortage in BC, which leads to staffing challenges.
- The requirement for clients to have an active provincial health number (PHN) to access provincially funded BC-CfE HIV PrEP and doxyPEP poses a barrier to some individuals, such as newcomers, and can restrict their ability to participate in BC-CfE HIV PrEP and doxyPEP programs. Additionally, criteria for doxyPEP exclude women and individuals who are not on HIV PrEP or HIV positive.
Lessons learned
- Clients have shared that the “one-stop-shop” approach to accessing HIV PrEP with experienced providers has eliminated barriers.
- Having a space that is welcoming and accessible increases clients’ comfort.
- Working to support those most at risk or those who experience specific barriers to care is essential to making people feel comfortable and improving access.
- Being responsive to the needs of the community served and listening to what people with living/lived experience, researchers and clinicians are saying is important and allows the team to respond quickly when changes happen (e.g., the introduction of new guidelines).
Program materials
- BC-CfE guidelines for HIV PrEP and doxyPEP:
Contact information
Kellie Guarasci (she/her)
Clinical Nurse Lead
Primary Care Nurse
Cool Aid Community Health Centre
1st floor, 713 Johnson Street
Victoria, BC
V8W 1M8
kguarasci@coolaid.org