Nurse-led PrEP clinic in San Francisco shares model of success at AIDS 2016
Truvada as PrEP was approved for use in the US in 2012, and has since been approved for use for HIV prevention in seven other countries. But many communities and countries are still struggling to figure out the best ways to provide PrEP. In the US, there’s been debate about who should provide PrEP—should it be reproductive health specialists? Primary care physicians? Infectious disease doctors? Or people who specialize in providing care to at-risk populations such as men who have sex with men, sex workers, or transgender people? Or all of the above?
The program by San Francisco AIDS Foundation, at the sexual health clinic in Strut, uses a nurse-led model of care to provide free, easy-to-access PrEP services to cisgender and transgender men who have sex with men. At the AIDS 2016 conference, Pierre-Cedric Crouch, PhD, ANP-BC, ACRN, the director of nursing at Strut, delivered a presentation about the progress of the program to researchers, health providers and community members in attendance.
“PrEP is easy, safe, effective and needed for people at substantial risk for HIV,” said Crouch. “We started the PrEP Health Program in San Francisco in 2014, and since that time have enrolled more than 1,250 people into the program. By coming to the AIDS 2016 conference in Durban, we hope to share with the rest of the world the success of our program—and show that it is feasible to implement programs that are led by nurses and run outside of a traditional medical setting.”
The PrEP Health Program by San Francisco AIDS Foundation launched in November 2014. Integral to the program is the provision of a complete set of services designed to help clients decide if PrEP is right for them, screen for PrEP eligibility, gain access to the medication with benefits navigation, and support clients with regular follow-up as they stay in the program. Clients can screen for PrEP—and if eligible—leave the clinic with a prescription for Truvada in under 90 minutes.
“When we launched our PrEP program, we took a moment to step back and figure out, ‘What are all the barriers people have to go through to access PrEP?,’” said Crouch. “We wanted it to be easy to access—we didn’t want people to have multiple visits or to have to wait to get onto PrEP, so we initiated a same-day PrEP protocol. Cost limitation is a huge issue, and we wanted to make sure people had the support and help they needed to access the benefits in order to have this medication fully covered.”
Progress and people served so far
Crouch reported that so far 1,252 people have been screened for the PrEP program, with over 95% enrolled. Cisgender men make up the bulk of clients (1,249) and a small minority (3) are transgender men. (Crouch noted that, since preparing the presentation, two additional transgender men have started PrEP through the program.)
On entering the program, most clients cited past condomless sex as the reason for desiring PrEP. A small percentage (3.8%) reported having an HIV-positive partner, and 3.5% sought PrEP despite being “low-risk,” with past reported consistent condom use. The mean number of sexual partners reported in the previous year, on entering the program, was 17.4 with a median of 10.
PrEP clients range in age from 18 to 72 with a mean of 35 years. Most (55%) are white followed by Hispanic/Latino (25%), Asian/Native American/Asian and Pacific Islander (12%); and Black (4%). Black and African American MSM in San Francisco are disproportionately affected by HIV in San Francisco, said Crouch, but still under-represented in the PrEP Health Program. “This is something we need to work on,” said Crouch.
Retention and adherence
Retention in the program is high, reported Crouch. Overall, 71% of people who started in the program are still returning for study visits. A snapshot in time of adherence by study visit number showed that adherence ranged from 77% to 88%.
Adherence to the medication dosing schedule also is high, with more than 90% of clients reporting missing three or fewer doses in the last seven days at all of the scheduled visits. “Most people are reporting that they are actually taking enough pills to have protection on PrEP,” said Crouch.
Sexually transmitted infections
Slightly more than 20% of clients had a sexually transmitted infection (STI) or were treated because they were a contact of someone who had an STI at baseline. STI rates hovered around 15% at each month of the study, except for month 13 (less than 10%) and month 16 (slightly less than 20%).
After being screened and treated for STIs at baseline, slightly less than 15% of clients returned with an STI or as a contact of someone with an STI after one month on PrEP.
“The main thing I want to highlight is month 1,” said Crouch. “There are actually a decent number of people that were treated as a contact after a month. When we look at the follow up involved when we see people, I feel like we could probably see them every month and have a meaningful number of infections we could treat,” said Crouch.
About 93% of people report having condomless sex at baseline. At each visit, Crouch reported that staff ask clients if their condom use changed has changed. Specifically, if it has increased, stayed the same, or decreased over time.
Do people change how they have sex on PrEP? Read about risk compensation in this BETA article Q&A with Kim Koester.
A higher percentage of people report more condomless sex at month 16 (47.6%) than in earlier months: month 1 (16.4%), month 4 (30.1%), month 7 (34.1%), month 10 (39%), and month 13 (37.8%).
No new HIV infections
Thus far, there have been zero new HIV infections among people in the PrEP program, and this includes people who miss visits and return after four to five months, said Crouch.
Two acute HIV infections were detected at study enrollment. There have been 82 HIV infections in the clinic—among people not on PrEP—since the PrEP Health Program launched.
“Community based organizations can step up to the plate and offer PrEP,” said Crouch. “Also, the nurse-led model can be successful in delivering PrEP. There are other organizations that have pharmacists who actually deliver PrEP. It makes sense to step back and think, ‘Who else in your organization can participate in this?’ It doesn’t necessarily have to be a physician-centered model every time. We know that PrEP is easy, safe, effective, and needed, so we just need to do it.”
Read more about the PrEP Health Program on BETA and visit their website to make an appointment for services.