No New HIV Infections in San Francisco Community PrEP Clinic
A trailblazing pre-exposure prophylaxis (PrEP) program by the San Francisco AIDS Foundation sexual health center Magnet was lauded at the 2015 HIV Prevention Conference. The PrEP health program began as a pilot program in November, 2014 and will continue to expand when it moves into a new health and wellness center, Strut, in San Francisco’s Castro neighborhood. In early December, Magnet director Steve Gibson, MSW, shared lessons learned about the PrEP health program—which has seen no new HIV infections—at the conference in Atlanta, Georgia.
With an increasing number of community and health groups interested in scaling up PrEP access programs, practitioners across the country had the opportunity to learn about Magnet’s model of care and how the center has been able to successfully enroll and retain people in the program.
The program started in November 2014 as a pilot program for people at risk of HIV but has expanded into a full-fledged PrEP health program with almost 700 men screened. PrEP is a method by which HIV-negative people can take a daily pill to prevent HIV infection.
“It was great to share our success at launching a nurse-led PrEP program showing that community-based organizations can, and need to, offer PrEP services for their clients,” said Gibson.
Some of the results presented at the conference appear below.
Who’s enrolling in the PrEP Program?
A total of 695 people have been screened for PrEP interest and eligibility with 90% enrolling in the program. The mean age of enrolled participants is 34 years with an age range of 18 to 71. Participants reported an average of 18.5 sexual partners per year with the most common reason for initiating PrEP being condomless sex (91%) followed by having an HIV-positive partner (12%). San Francisco AIDS Foundation recently opened a PrEP clinic at their main office located between the Tenderloin and South of Market neighborhoods of San Francisco which will increase access to PrEP services for transgender women and non-gay identified men who have sex with men.
Is condom use decreasing?
The majority of people enrolled in the PrEP health program reported the same or more condom-protected sex at each time point (72% at month 1; 70% at month 4; 63% at month 7).
“We found that most men do not increase the amount of condomless sex while on PrEP,” said Pierre-Cédric Crouch, PhD, ANP-BC, the nursing director at Magnet. “About 91% of our clients were already having condomless sex when they started PrEP, so condomless sex was already high among our participants to begin with. But this is less than a year’s worth of data. With more time we will be better able to understand how PrEP impacts a person’s life.”
PrEP retention & adherence
The program boasts high retention rates, with 79% of people completing the month 1 visit, 78% completing the month 4 visit and 80% completing the month 7 visit.
At each visit, PrEP program participants are asked the question, “How many doses have you missed in the last seven days?”
“We ask about the number of doses people have missed because we want to get an accurate assessment of how adherent people are being to the daily regimen. We ask how many doses have been missed as opposed to if they have missed any doses so that people feel comfortable telling us about missed doses. There can be a response bias if you ask questions where one answer is considered more acceptable—clients may want to say they are doing the ‘right’ thing to make their provider happy. Saying it’s okay to miss a dose and asking how many doses they missed helps you build an adherence plan together with the client,” explained Crouch.
Daily use of PrEP is the only method approved by the U.S. Food and Drug administration. Seven does per week has been shown to provide the highest level of protection, while at least four doses per week provides an estimated 96% reduction in HIV risk. Gibson reported that participants maintained high adherence—defined as missing fewer than 3 doses in the past 7 days. At the month 1, 4 and 7 visits, 95%, 97% and 94% of participants, respectively, reported high adherence.
Sexually transmitted infections
PrEP program participants receive STI testing (and treatment, if needed) at every 3-month visit. At baseline, 4% of participants were treated for a rectal STI and 22% were treated for a pharyngeal or urethral infection or because they had sexual contact with another person diagnosed with an STI.
The incidence rates of STIs remained steady across visits, with rectal STI incidence rates ranging from 2% to 5% and the incidence rates of other STIs/STI contact ranging from 15% to 23%.
“STI rates stayed pretty much stable, but that wasn’t too surprising since people didn’t change their behavior much. It means that we are finding the right people to put on PrEP. Most importantly, there were no new HIV infections.” explained Crouch.
The model of care
At Magnet, nurse practitioners medically clear clients for PrEP, prescribe the drug Truvada and conduct medical follow-ups. Once a client has been determined to be medically eligible to take PrEP, they meet with a benefits navigator who helps them figure out how to pay for PrEP by taking advantage of existing insurance benefits, MediCal or copay assistance programs.
“Our program is structured to reduce as many barriers as possible that people may encounter when accessing PrEP. People can enroll in the PrEP health program in one visit. After seeing a nurse practitioner and if found to be eligible to take PrEP, clients meet with a benefits navigator. That same day, clients can walk out with a prescription for Truvada in hand, and know how they’re going to pay for it,” said Gibson.
The PrEP Health Program will continue when the Magnet clinic moves to Strut, at 470 Castro Street, San Francisco. Strut will open for drop-in appointments on January 4, 2016.