Leading community-led PrEP services are rethinking how they deliver services while reaching beyond their traditional user base. Facing waiting lists of thousands, the clinics are streamlining care and developing new strategies to engage trans people and migrant men who have sex with men. These were among the approaches shared at the 2nd European Workshop on Breaking PrEP Barriers, held in Barcelona last week.
The workshop was put in place by BCN Checkpoint, a community-led sexual health centre in Barcelona that has itself provided PrEP to 5347 people in the last six years. That represents 15% of all PrEP users in Spain, and 44% of PrEP users in the autonomous community of Catalonia. What’s more, 88.7% of people who start PrEP are still receiving it 24 months later, an unusually high level of retention.
“Why do we have this high demand?” asked Javier Fernández, a nurse at BCN Checkpoint. “I think one of the reasons is because we are a community centre and it's peer-to-peer – when a person walks through the door, they feel safe and that they are in a space of trust.”
Nurses aim to deliver all aspects of follow-up PrEP care, including taking bloods, advising on appropriate use and dispensing the medication, in a single visit. But they may also offer advice and services related to vaccinations, chemsex, emotional wellbeing and engagement with the healthcare system. “We need to be clear that PrEP is not simply a prescription or the monitoring of a drug, it's something more – it's comprehensive support,” Fernández said.
This care is delivered in a non-paternalistic way. “As physicians, but also as nurses or community leaders, we need to break the model that we have to tell people what to do and how to do it,” said Dr José Miguel Cabrera, a physician at BCN Checkpoint. Their role is to understand what service users want to know and help them find the information that will allow them to make the right decision for themselves, he said. “The correct option for me is not going to be the same for someone else.”
However, BCN Checkpoint does not receive direct public funding and PrEP can only be provided thanks to a complex partnership with a university hospital (medical staff are hospital employees, for example). Moreover, budget restrictions limit the number of people who can get PrEP either at Checkpoint or at other PrEP providers in Catalonia – some hospitals won't accept more than 200 PrEP users.
The result is that 4150 people are on the waiting list for PrEP at BCN Checkpoint, with an average wait time of over two years. This causes multiple problems, including 20 people seroconverting while on the waiting list, others feeling demotivated and dropping out, and the administrative burden of following patients up. More fundamentally, Fernández said the lack of access to healthcare raises questions of equity and justice.
Some of the other speakers at the workshop represent the leading PrEP providers in their settings. Le 190, a community-led clinic in Paris, started 531 people on PrEP in 2024, more than any other site in France. “I'm not proud of that, I'm ashamed of that,” said the centre’s founder Dr Michel Ohayon. “It means that the others stopped doing their job.”
Simplifying and streamlining
Providers facing high levels of demand are searching for ways to simplify their services and free up capacity for other people who need PrEP. As well as making things easier for the healthcare providers, they are also aiming to reduce the burden for PrEP users, without sacrificing the quality of care.
Dr Elske Hoornenborg of the Public Health Service of Amsterdam pointed to a randomised study she was involved in which PrEP users had their follow-up visits either every three months or every six months, and they were done either face-to-face or online. Outcomes in terms of the effective use of PrEP (participants were asked how often they had had anal sex that wasn’t covered by either PrEP or condoms) and sexually transmitted infections were comparable.
There is a wider move to reduce the frequency of STI screening, especially the screening and treatment of people who don’t have symptoms. This is driven by concerns around the overuse of antibiotics and the spread of antimicrobial resistance, coupled with a lack of evidence that asymptomatic screening and treatment reduces STI prevalence at a population level. For example, following a Dutch study which found that asymptomatic chlamydia did not increase the risk of pelvic inflammatory disease (whereas symptomatic chlamydia did), many Dutch services there have stopped screening for chlamydia when there are no symptoms. Belgian PrEP guidelines only recommend testing for chlamydia and gonorrhoea if there are symptoms.
“We have to stop with unnecessary testing and medication,” Hoornenborg said.
BCN Checkpoint initially changed the way they did quarterly follow-up appointments – every other one was done online, with the PrEP user completing an HIV self-test, provided they were stable on PrEP, with no adherence issues and good kidney function. “With this small change alone, we managed to increase the number of people we see by 20%,” Fernández said. They are now further simplifying, with six-monthly visits.
At 56 Dean Street in London, five nurses provide around 150 PrEP consultations each day and follow around 25,000 PrEP users. Dr Gary Whitlock acknowledged that "it is a bit like a factory", with streamlined processes that both maximise the efficiency of the service and limit the amount of time PrEP users need to devote to medical appointments. Users order test kits for HIV and sexually transmitted infections online and then mail in their samples before a clinic visit. If test results are all fine and they have a recent enough kidney test result, repeat PrEP users may be able to have their PrEP refill mailed out to them.
Once people are stable on PrEP at Le 190 in Paris, the centre may ask them if they would be happy to have their follow-up PrEP care at their general practitioners (GPs). This also has the advantage of giving GPs – who have been permitted to start patients on PrEP since 2021 – more experience of PrEP.
Continuing the movement towards simplifying and de-medicalising PrEP delivery may be challenging when PrEP is an injection rather than a pill, warned Professor Raphael Landovitz of the University of California. The injections must be delivered by a clinician and require regular face-to-face attendance, while guidelines often include more complex testing requirements. He suggested looking to family planning clinics as a potential model, noting their experience in providing multiple contraceptive methods and their systems for providing injections, tracking patient attendance, and following up with those who miss appointments.
Bringing PrEP to new populations
Although 56 Dean Street makes it easy for people who know they want PrEP to get it, they are also systematic in offering PrEP to some other patients. “If you have a bacterial rectal STI, you will leave with PrEP after your STI treatment,” Dr Gary Whitlock said. “That is a risk for HIV, so why wouldn’t you?” Similarly, PrEP is offered on an opt-out basis to everyone with early syphilis, who reports chemsex, or is prescribed post-exposure prophylaxis (PEP).
And while 56 Dean Street, Le 190 and BCN Checkpoint all have their roots in gay communities, and have had great success engaging men from those communities with high levels of sexual health need, they are now being more intentional in their efforts to go beyond this core user base and to reach underserved groups.
In France, HIV diagnoses have been falling for several years among French-born men who have sex with men (MSM). However, among MSM born overseas, diagnoses have been increasing, both as a proportion of all diagnoses and in absolute numbers. Michel Ohayon described using outreach on dating apps to reach underserved migrant MSM – crucially, they concentrated on apps which are less associated with gay identity or which are used to find escorts. Those contacted had high levels of sexual health need and low levels of PrEP use. They were invited to attend a clinic, where 75% of the men offered PEP or PrEP accepted it.
Checkpoint Zurich has been working to improve their engagement with trans people over the last decade. “We realised that the MSM world and the trans world is not such a happy family – there are barriers between those two groups,” said Dr Benjamin Hampel, the chief physician there. They had to put considerable effort into staff training so as to develop the team’s cultural competency. “You have to learn how to speak to trans people in a non-stigmatising way,” he said. “You don’t just do it because you're a nice person.”
A crucial step in this process was hiring more trans staff. They helped the team identify problems and solutions, including adapting the patient registration and IT systems so that gender is not treated as a binary. There’s an evening once a month when only trans people can attend, and an outreach clinic in the red-light district brings the service to trans people who sell sex.
But Hampel stressed the importance of Zurich Checkpoint also providing hormone therapy, which is usually trans people’s number one health priority. His advice to other services: “Offer gender affirming care, because otherwise you will never open the door for PrEP.”
Full image credit: PrEP providers at the European Workshop on Breaking PrEP Barriers. From left to right: Dr Mar Vera, Centro Sandoval, Madrid; Dr Gary Whitlock, 56 Dean Street, London; Dr Benjamin Hampel, Checkpoint Zurich; Dr Susana Muñoz, Hospital Germans Trias i Pujol, Barcelona; Dr Michel Ohayon, Le 190, Paris; Javier Fernández, BCN Checkpoint, Barcelona; and Dr Pep Coll, BCN Checkpoint, Barcelona. Photo by Carlos Oró.