Same-day HIV Pre-Exposure Prophylaxis in an urban sexually transmitted infection clinic
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.
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.
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.
The Maple Leaf PrEP Clinic – case study
Text Message Reminders – program element
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.
- 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.