Pre-exposure prophylaxis (PrEP), using oral tenofovir/emtricitabine in the form of Truvada® was approved by the United States of America Federal Drug Administration in 2012. In October, 2014, the Centers for Disease Control and Prevention (CDC) guidelines were utilized to develop practice protocols for a PrEP program in an urban, community based sexual health clinic for individuals aged 18 and over who identify as men who have sex with men (MSM) or transgender (site one). A free program was launched in November, 2014 , using 1.6 full time equivalent nurse practitioners (NPs) offering appointments Monday through Saturday, and benefits navigators to assist clients in obtaining coverage for the cost of PrEP.
Initial visits included complete history and physical, review of co-morbidities and contraindications to PrEP, adherence and safer sex practices counseling, and sexually transmitted infection (STI) testing . In order to meet the prescribed safety criteria, point of care testing was utilized for rapid complete metabolic panel (CMP), HIV and hepatitis C antibody testing, enabling the NPs to prescribe medication at the initial visit. Follow-up visits included HIV and STI testing, CMP, review of adherence to PrEP, STI treatment as needed and safe sex counseling.
Demand for PrEP was high, and those accessing the service were predominately white (55%). Other races included, Hispanic (24%), Asian Pacific Islander (12%) and Black (4%). Trans-men accessed services but trans-women and intravenous drug users did not. The age range was 18-72, the median age was 35 and the mean number of sexual partners was 17.
Feedback from community partners revealed that the location of the clinic—in a gay friendly predominately white area—was a barrier to access for HIV prevention services for trans-women, sex workers, and MSM of color. In order to address this disparity, in September, 2015, a satellite PrEP clinic (site 2) was launched in a high poverty urban neighborhood within an existing HIV community services site. This second PrEP program was available two mornings a week. One NP registered the clients, collected their blood work, anal and pharyngeal swabs, and urine samples and then completed the HIV, Hepatitis C and renal function point of care testing. The NP then collected a health history, completed a physical assessment, and provided education regarding PrEP, adherence counseling and safe sex counseling.
The development of the second site expanded services to sex workers, transgender persons, intravenous drug users, persons of color and MSM unaware of the primary site. The age range for clients at the second site was 20-54, and the median age 31. Although this site also predominately attracted white MSM (47%), 20% of clients reported being unaware of site 1 and its services. This site also attracted Blacks (10%), and Other Race (7%). There were proportionately fewer Asian Pacific Islanders (9%) and Hispanics (21%) at site 2 than at site 1.
Community referrals created a need to expand the PrEP services at both sites, and to accomplish this, phlebotomists and benefits navigators from existing HIV testing services were utilized. In addition, nursing protocols were developed, within the scope of practice of California registered nurses (RNs), to allow RNs to complete follow-up visits, allowing the NPs to offer more PrEP enrollment visits at both sites. Further feedback from community partners led to the clinic times being changed to one morning and one afternoon per week, with 2 new visits with 2-3 follow up visits available during each session.
Currently the two sites provide HIV prevention services to over 1,600 individuals and enroll up to 40 new clients a week. There have been zero HIV infections in this program and ways to increase PrEP services throughout the San Francisco community are being explored.
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