For pre-exposure prophylaxis (PrEP) to have a substantial public health impact, access to PrEP needs to be improved so that more people who would benefit from it receive PrEP. Services need to adapt and innovate. A series of recent articles, most of them published in a special issue of Sexual Health, outline a range of promising approaches.
PrEP provision may challenge sexual health services because of the large influx of new patients who will need to attend quarterly. These services may need to be reconfigured to create more appointment slots.
“Task shifting” involves delegating tasks from health workers who are in short supply – such as doctors – to other staff members, such as nurses. It has been instrumental in expanding access to HIV treatment in African countries and Dr Heather-Marie Schmidt of the New South Wales Ministry of Health says that it has played a crucial role in the massive scale-up of PrEP there. A nurse-led model has increased the capacity of clinics to rapidly expand PrEP, without calling on extra resources.
Within the EPIC-NSW trial, registered nurses can screen, educate, clinically assess, order tests and manage results. Extensive planning and consultation with stakeholders was needed to create an acceptable and legally valid procedure that would allow nurses to provide PrEP medication. The nurses are delegated responsibility by a senior physician at their clinic to dispense PrEP medication at the clinic, within clearly set parameters and with each patient’s records being regularly reviewed by a doctor. People with kidney problems, suspected HIV seroconversion, abnormal test results or side-effects are referred to a doctor.
Registered nurses are authorised to initiate people on PrEP, but most clinics have chosen to have this handled by a doctor, with nurses conducting follow-up appointments. These may take place at community-based testing sites, which may be more convenient for the person taking PrEP.
Providing PrEP in community pharmacies
Existing PrEP services are often at a significant geographic distance from many people. In the United States, people living outside of cities and in southern states are especially unlikely to have local access to PrEP. However, most people live close to a community pharmacy and pharmacists already provide screening for a range of health issues as well as helping to manage long-term conditions like cardiovascular disease.
In Seattle, the Kelley-Ross pharmacy created a PrEP service. It set up a Collaborative Drug Therapy Agreement with an HIV specialist physician, which allows trained pharmacists to perform specific functions, including initiating and monitoring PrEP in line with national guidelines. As with the nurse-led service in New South Wales, complex cases are referred to the physician.
The service is called One-Step PrEP and marketing emphasises that all steps for PrEP initiation (including testing, getting results and picking up medication) are done at the pharmacy, usually in one visit. In addition, pharmacists have experience in helping people navigate health insurance requirements, authorisations and applications for co-payment cards.
Success of the service is facilitated by the state of Washington’s supportive policies. It has expanded Medicaid and there is a PrEP drug assistance programme. Moreover, legislation gives pharmacists a wide scope of practice and requires commercial insurers to recognise pharmacists as healthcare providers.
Digital health services
Digital health services (also known as telehealth services) use communication technologies to exchange data between an individual at home and a clinical team, allowing health care to be provided at a distance. In San Francisco, the PrEPTECH programme was marketed to young gay and bisexual men of colour. They could access a mobile-optimised website to get information about the service and to be screened for PrEP. Eligible participants were mailed a self-sampling kit for sexually transmitted infections and were referred to a local laboratory for HIV and kidney blood tests. Phone appointments with a doctor were used for both PrEP initiation and regular follow-up, with medication sent by post. Users could choose to receive mobile phone reminders for medication adherence and appointments.
The programme has some similarities with PrEP@Home, which we reported on a few months ago. PrEP@Home has the advantage of using self-sampling for all necessary tests (thereby dispensing with the need for laboratory visits). However, users were required to attend a face-to-face appointment once a year, whereas all PrEPTECH appointments were by phone.
In a small pilot study, most PrEPTECH users said that it was more convenient, faster and easier to use than other ways of accessing PrEP.
Digital mentoring for local PrEP providers
Healthcare providers who currently have limited experience of PrEP may need training and mentoring to support them to deliver PrEP. If this support can be delivered across wide geographic areas, a more comprehensive network of PrEP providers can be developed.
Project ECHO faciliates knowledge-sharing networks in medicine, using videoconferencing to conduct virtual clinics with community healthcare providers. In the US, one such network educates and mentors community HIV practitioners in the states of Washington, Oregon, Montana, Idaho, Utah and Alaska.
In 2015 it added regular content on PrEP – quarterly talks by experts plus monthly case discussions, based on situations that had arisen in the participants’ own practice. Most cases focused on identifying appropriate individuals to receive PrEP, considerations for serodiscordant couples (including conception) and transitioning from post-exposure prophylaxis (PEP) to PrEP.
Participants reported that taking part improved their knowledge and confidence in prescribing PrEP, helping them manage individual patients. Dr Brian Wood of the University of Washington says the programme served as a catalyst for them to be PrEP champions and become a resource for other healthcare providers in their communities.
Key population-led services
In Thailand, around 85% of the country’s estimated 6600 PrEP users are obtaining PrEP from a service which is led by community health workers drawn from the key populations affected by HIV.
One of these is the Princess PrEP programme, which works with organisations such as Adam’s Love, the Rainbow Sky Association and Swing that have strong links with communities of men who have sex with men and transgender women. PrEP was added into existing services, which offer cash incentives to peer mobilisers who bring people in for HIV testing provided by community health workers. If the test result is reactive, HIV treatment is offered. If the result is negative, a prevention package is offered, including condoms, lubricant, PEP and PrEP.
The individual taking the test and the peer health worker decide together whether PrEP would be appropriate. Around one in ten decide to take PrEP and the medication is dispensed the same day by the community worker. One challenge is retention, which drops to around 50% after one year, with poorer results seen in younger and less educated individuals.
Engagement with PrEP has been much better in key population-led services than in Thailand’s public hospitals (less than 5% of the country’s PrEP users). Dr Nittaya Phanuphak of the Thai Red Cross says this shows that “PrEP needs to be urgently demedicalised” to facilitate uptake. But the World Health Organization does not currently recommend this model of care. “To scale-up and sustain key population-led PrEP programs, strong endorsement from international and national guidelines is necessary,” she says.
Holistic services for transgender women
Many transgender women do not feel comfortable using mainstream health services. In Detroit, 54% said that they had felt disrespected at health facilities, 59% had postponed getting services because clinics were not trans-inclusive and 81% said they would prefer to use a clinic that specialises in transgender care.
The city’s Ruth Ellis Health and Wellness Center has been able to engage transgender women with PrEP by offering it alongside gender-affirming hormone therapy. Blood samples for the laboratory tests needed for both PrEP and hormone therapy are drawn at the same time. Similarly, adherence support for the two interventions is integrated. Prescriptions can be delivered onsite, avoiding the need to visit a pharmacy where a person may encounter discrimination.
The Ruth Ellis Center is trusted as a safe and supportive space in Detroit’s transgender community. It provides a wide range of physical, behavioural and psychosocial health services; provides support to people selling sex; has a drop-in centre that provides access to food, showers and computers; provides case management services; and has expertise in navigating health insurance requirements.
Specialist and holistic services like these may be needed to reach marginalised transgender women.
Zablotska IB et al. Getting pre-exposure prophylaxis (PrEP) to the people: opportunities, challenges and examples of successful health service models of PrEP implementation. Sexual Health 15: 481-484, 2018. (Abstract.)
Sullivan PS & Siegler AJ. Getting pre-exposure prophylaxis (PrEP) to the people: opportunities, challenges and emerging models of PrEP implementation. Sexual Health 15: 522-527, 2018. (Abstract.)
Schmidt HM et al. Nurse-led pre-exposure prophylaxis: a non-traditional model to provide HIV prevention in a resource-constrained, pragmatic clinical trial. Sexual Health 15: 595-597, 2018. (Abstract.)
Refugio O et al. PrEPTECH: a Telehealth-Based Initiation Program for HIV Pre-exposure Prophylaxis in Young Men of Color Who Have Sex With Men. A Pilot Study of Feasibility. Journal of Acquired Immune Deficiency Syndromes 80: 40-45, 2019. (Abstract.)
Tung EL et al. Implementation of a community pharmacy-based pre-exposure prophylaxis service: a novel model for pre-exposure prophylaxis care. Sexual Health 15: 556-561, 2018. (Abstract.)
Wood BR et al. Project ECHO: telementoring to educate and support prescribing of HIV pre-exposure prophylaxis by community medical providers. Sexual Health 15: 601-605, 2018. (Abstract.)
Phanuphak N et al. Princess PrEP program: The first key population-led model to deliver pre-exposure prophylaxis to key populations by key populations in Thailand. Sexual Health 15: 542-555, 2018. (Full text freely available.)
Hood JE et al. Getting pre-exposure prophylaxis to high-risk transgender women: lessons from Detroit, USA. Sexual Health 15: 562-569, 2018. (Abstract.)