Decentralizing the delivery of HIV pre-exposure prophylaxis (PrEP) through family physicians and sexual health clinic nurses: a dissemination and implementation study protocol

Abstract Background Pre-exposure prophylaxis (PrEP) effectively reduces HIV acquisition, but its efficacy depends on continued engagement through periods of high and low risk. Persistence in HIV prevention care has been low in real-world settings. In our program, 32% of patients are lost to care after their first visit and only 35% of patients are retained at their planned third visit. Reasons for low persistence in care are poorly described. Methods We identified all MSM who started PrEP between July 2015 and June 2018 at a sexual health clinic in an urban academic medical center in New York and had not had a visit in ≥6 months. We called patients between July 2018 and January 2019; those who were English speaking were given the option to complete an online questionnaire about current PrEP status, reasons for disengagement, and social and behavioral determinants of health (SBDH). Results Up to 710 patients were eligible for the study; over 700 calls were made. 125 participants agreed to participate and 57 (46%) completed the questionnaire. 24 patients (42%) were still actively taking PrEP. The most common reasons for starting PrEP were fear of getting HIV (58%), high self-perceived HIV risk (28%), and recommendations from friends (26%). Among those no longer taking PrEP, the most common reasons for discontinuation were cost/insurance issues (32%), lower perceived HIV risk (18%), concern about long-term side effects (12%), and trouble attending every-3-month appointments (12%). For those stopping due to lower perceived risk, 40% were in a monogamous relationship, 60% were less sexually active, and 20% always used a condom or did not engage in receptive anal intercourse. 56% of patients had at least 1 major life event in the preceding 3 months, including loss of a job (25%), breakup with a partner (12%), illness or death of a family member (11%), or unstable housing (8%). 47% used drugs or alcohol before sex in the past month including 39% not on PrEP. Conclusion Reasons for engagement, disengagement, and re-engagement are highly variable at the individual level. Cost and insurance issues were common in spite if clinic resources available to cover the cost of visits and medications. Life trauma was common. Individualized interventions to address SBDH may be required to engage and retain individuals in HIV prevention care. Disclosures All authors: No reported disclosures.

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Fuckbuddy partnerships among men who have sex with men – a marker of sexually transmitted infection risk

International Journal of STD & AIDS ◽

10.1177/0956462417717647 ◽

2017 ◽

Vol 29 (1) ◽

pp. 44-50 ◽

Cited By ~ 2

Author(s):

Vincent J Cornelisse ◽

Christopher K Fairley ◽

Tiffany Phillips ◽

Sandra Walker ◽

Eric PF Chow

Keyword(s):

Sexual Health ◽

Health Centre ◽

Romantic Attachment ◽

Sexual Partners ◽

Health Clinic ◽

Transmitted Infection ◽

Sexually Transmitted ◽

Hiv Prevention Strategies ◽

Sex With Men ◽

Exposure Prophylaxis

‘Fuckbuddies’ are a type of regular sexual partner with whom men have ongoing sexual contact, generally in the absence of romantic attachment. We surveyed 989 men who have sex with men (MSM) at the Melbourne Sexual Health Centre, Australia, with the aim of determining the frequency of ‘fuckbuddy’ partnerships among sexual health clinic attendees and assessing their sexual risk. The majority (60%) of 1139 regular partnerships were described as ‘fuckbuddies’. Most MSM (63%) with a ‘fuckbuddy’ had multiple ‘fuckbuddies’. MSM with ‘fuckbuddies’ were more likely to also have casual sexual partners (odds ratio [OR] 5.7; 95% confidence interval 3.6–8.9) and had more casual sexual partners (median of 4 versus 1, p < 0.001) and more rectal chlamydia (12.4% versus 5.7%; adjusted OR 2.3; p < 0.05) than MSM without ‘fuckbuddies’, and this risk persisted after adjusting for total numbers of sexual partners. Our findings suggest that patients with ‘fuckbuddies’ are at particular risk of sexually transmitted infections. We argue that clinicians should specifically ask about ‘fuckbuddy’ partnerships as part of their risk assessment during patient interviews, as these patients may benefit from HIV prevention strategies such as pre-exposure prophylaxis (PrEP).

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Pre-exposure prophylaxis prescribing and retention in care among heterosexual women at a community-based comprehensive sexual health clinic

AIDS Care ◽

10.1080/09540121.2017.1286287 ◽

2017 ◽

Vol 29 (7) ◽

pp. 866-869 ◽

Cited By ~ 17

Author(s):

Oni J. Blackstock ◽

Viraj V. Patel ◽

Uriel Felsen ◽

Connie Park ◽

Sachin Jain

Keyword(s):

Sexual Health ◽

Retention In Care ◽

Health Clinic ◽

Community Based ◽

Heterosexual Women ◽

Exposure Prophylaxis

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HIV Pre-exposure Prophylaxis (PrEP) Uptake and Retention Among Men Who Have Sex with Men in a Community-Based Sexual Health Clinic

AIDS and Behavior ◽

10.1007/s10461-017-2009-x ◽

2017 ◽

Vol 22 (4) ◽

pp. 1096-1099 ◽

Cited By ~ 57

Author(s):

J. Carlo Hojilla ◽

David Vlahov ◽

Pierre-Cedric Crouch ◽

Carol Dawson-Rose ◽

Kellie Freeborn ◽

...

Keyword(s):

Sexual Health ◽

Health Clinic ◽

Community Based ◽

Sex With Men ◽

Exposure Prophylaxis

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Follow-up of renal impairment results among attendees taking HIV Pre-Exposure Prophylaxis at a Sydney Sexual Health Clinic

International Journal of STD & AIDS ◽

10.1177/0956462420922751 ◽

2020 ◽

Vol 31 (7) ◽

pp. 689-693

Author(s):

NB Comninos ◽

R Foster ◽

R Varma ◽

C Bourne

Keyword(s):

Renal Impairment ◽

Sexual Health ◽

Service Provision ◽

Filtration Rate ◽

Estimated Glomerular Filtration Rate ◽

Health Centre ◽

Health Clinic ◽

Immunodeficiency Virus ◽

Exposure Prophylaxis

Renal monitoring is recommended for Pre-Exposure Prophylaxis (PrEP) users. We aimed to explore follow-up and outcomes among PrEP users with renal impairment (defined as estimated glomerular filtration rate <65 mL/min/1.73 m2) attending Sydney Sexual Health Centre. Time to follow-up was analysed for impairment results over a 12-month period (January–December 2018); 48/2504 (1.9%) tests among 1700 attendees showed impairment. Follow-up occurred in 39/48 (81.3%) impairment results after a median of 42 days. PrEP was ceased in 3/6 cases of non-resolving/persisting impairment, with one case of subsequent human immunodeficiency virus infection. Maintaining engagement and follow-up of those with renal impairment are important aspects of PrEP service provision.

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Pre-Exposure Prophylaxis Counseling in a Community Sexual Health Clinic for Men Who Have Sex with Men in Lisbon, Portugal

Acta Médica Portuguesa ◽

10.20344/amp.11474 ◽

2019 ◽

Vol 32 (6) ◽

pp. 441 ◽

Cited By ~ 3

Author(s):

Sofia Ribeiro ◽

Miguel Rocha

Keyword(s):

National Health Service ◽

Health Service ◽

Sexual Health ◽

National Health ◽

Antiretroviral Drugs ◽

Health Clinic ◽

Eligibility Criteria ◽

Sex With Men ◽

Exposure Prophylaxis

Introduction: Pre-exposure prophylaxis is defined as the use of antiretroviral drugs to prevent HIV acquisition in uninfected individuals. Recognizing the increasing use of informal pre-exposure prophylaxis in Portugal, CheckpointLX, a community clinic targeted to men who have sex with men in Lisbon, Portugal, began offering counselling and follow-up services prior to formal introduction. This study aims to characterize pre-exposure prophylaxis users attending CheckpointLX before formal pre-exposure prophylaxis introduction in Portugal, and those who were referred to pre-exposure prophylaxis in the National Health Service following formal approval of pre-exposure prophylaxis.Material and Methods: Data was collected by peer counsellors between May 2015 and September 2018 and inserted in a database. Medical care followed the European AIDS Clinical Society recommendations for pre-exposure prophylaxis eligibility, initiation and follow-up. For formal pre-exposure prophylaxis, the General-Directorate for Health’s Pre-exposure Prophylaxis guidelines checklist was used.Results: Until the end of May 2018, CheckpointLX had a total of 90 appointments for wild pre-exposure prophylaxis, of which 64 (71%) were first time visits. As for the 380 service users referred to the National Health Service, most were Portuguese (n = 318, 84%), and the mean age was 31 (8.9) years old. Condomless sex in the last six months with partners of unknown HIV status was the most common eligibility criteria (n = 59, 83%).Discussion: Pre-exposure prophylaxis delivery should be complemented with effective information on the importance of immunization and education on safer practices of drug administration, in the scope of broader preventive sexual health care.Conclusion: Much remains to be done in Portugal to ensure that pre-exposure prophylaxis is available to those who need it the most. Offering pre-exposure prophylaxis at community clinics could be a first step.

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Hepatitis A vaccine uptake among men who have sex with men from a time-limited vaccination programme in Melbourne in 2018

Sexually Transmitted Infections ◽

10.1136/sextrans-2019-054132 ◽

2019 ◽

Vol 96 (2) ◽

pp. 110-114 ◽

Cited By ~ 2

Author(s):

Sam Burrell ◽

Lenka A Vodstrcil ◽

Christopher K Fairley ◽

Alex Kilner ◽

Catriona S Bradshaw ◽

...

Keyword(s):

Sexual Health ◽

Vaccination Programme ◽

Hepatitis A ◽

Health Centre ◽

Vaccine Uptake ◽

Health Clinic ◽

Sex With Men ◽

Exposure Prophylaxis ◽

Living With Hiv ◽

To Receive

ObjectivesIn 2017, an outbreak of hepatitis A among gay, bisexual and other men who have sex with men (MSM) was reported in Victoria, Australia. In 2018, the Victorian government implemented a free hepatitis A vaccination programme targeting all Victorian MSM. This study aimed to determine hepatitis A vaccine uptake among MSM in a sexual health clinic in Melbourne.MethodsAll MSM attending the Melbourne Sexual Health Centre (MSHC) in 2018 were included. Chart review was performed to determine the proportion of men vaccinated for at least one dose of hepatitis A and to examine why men did not receive the vaccine. Multivariable logistic regression was performed to examine the factors associated with vaccine uptake. Vaccine uptake was defined as receipt of at least one dose of hepatitis A vaccine.ResultsOf the 9582 MSM who attended MSHC in 2018, 61.3% (95% CI 60.3% to 62.2%) self-reported already being immune to hepatitis A. Of the 3713 remaining eligible men, 62.7% (95% CI 61.1% to 64.2%) received at least one dose of the hepatitis A vaccine on the day of attendance. Compared with MSM not living with HIV and not taking pre-exposure prophylaxis (PrEP), MSM taking PrEP (adjusted OR 1.28; 95% CI 1.01 to 1.62) were more likely to receive the vaccine. 1386 men (37.3%) did not receive the vaccine and 55.4% were not offered the vaccine by their treating clinician. 300 men (21.6%) were identified as non-immune after serological testing but did not return for vaccination. By the end of 2018, 85.5% of MSHC attendees (8196/9582) were immune to hepatitis A.ConclusionThe critical vaccination threshold for hepatitis A has been estimated at >70%. Continuation of the targeted hepatitis A vaccination programme will improve immunity among the MSM population to prevent ongoing transmission and the likelihood of future outbreaks.

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Non-occupational HIV post-exposure prophylaxis at a Sydney metropolitan sexual health clinic

Sexual Health ◽

10.1071/sh13018 ◽

2013 ◽

Vol 10 (5) ◽

pp. 438 ◽

Cited By ~ 6

Author(s):

Trine Gulholm ◽

Salina Jamani ◽

I. Mary Poynten ◽

David J. Templeton

Keyword(s):

Sexual Health ◽

Risk Behaviour ◽

Anal Intercourse ◽

Unprotected Anal Intercourse ◽

Health Clinic ◽

Post Exposure Prophylaxis ◽

Prescribing Practices ◽

Post Exposure ◽

Hiv Seroconversion ◽

Exposure Prophylaxis

Background Non-occupational HIV post-exposure prophylaxis (NPEP) is prescribed following a risk exposure in an effort to reduce the risk of HIV seroconversion. We aimed to describe the prescribing practices of NPEP at RPA Sexual Health in Sydney, the prevalence and correlates of adverse events (AEs), and factors associated with completing the 28-day course. Methods: The study population included individuals prescribed NPEP during January 2008–December 2011. Correlates of AEs and course completion were assessed by logistic regression. Results: On 319 occasions during the study period, 282 individuals presented for NPEP. Over 90% of presentations followed unprotected anal intercourse between men, mostly receptive (63.6%). Tenofovir–emtricitabine–stavudine (n = 149; 46.7%) and tenofovir–emtricitabine (n = 136; 42.6%) were most commonly prescribed. AEs were reported at 101 presentations (31.7%, 95% confidence interval (CI): 26.6–37.1%), with nausea and lethargy/malaise being the most common. Younger age (P for trend = 0.032), earlier year of NPEP prescription (P for trend = 0.011), being prescribed a regimen other than tenofovir–emtricitabine (P = 0.026), changing the NPEP regimen (P < 0.001) and known completion of the course (P = 0.005) were independently associated with AEs. The course was completed in 228 presentations (71.5%, 95% CI: 66.2–76.4%). Completion was associated with reporting AEs (P = 0.007) and changing regimen (P = 0.001). No documented NPEP failures were identified, although two recipients subsequently seroconverted to HIV due to ongoing high-risk behaviour. Conclusions: NPEP is appropriately targeted to the highest risk HIV exposures at our clinic. Active recall may improve follow-up rates in NPEP recipients.

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Early impact of COVID-19 social distancing measures on reported sexual behaviour of HIV pre-exposure prophylaxis users in Wales

Sexually Transmitted Infections ◽

10.1136/sextrans-2020-054598 ◽

2020 ◽

pp. sextrans-2020-054598

Author(s):

David Gillespie ◽

Carys Knapper ◽

Dyfrig Hughes ◽

Zoe Couzens ◽

Fiona Wood ◽

...

Keyword(s):

Sexual Health ◽

Sexual Behaviour ◽

Control Measures ◽

Relationship Status ◽

Health Clinic ◽

Social Distancing ◽

Condomless Sex ◽

Health Clinics ◽

Sexual Health Clinics ◽

Exposure Prophylaxis

ObjectivesTo describe the early impact of COVID-19 and associated control measures on the sexual behaviour of pre-exposure prophylaxis (PrEP) users in Wales.MethodsData were obtained from an ecological momentary assessment study of PrEP use and sexual behaviour. Participants were individuals accessing PrEP through the National Health Service (NHS) sexual health clinics across four health boards in Wales. Weekly data documenting condomless sex in the preceding week were analysed between 03/02/2020 and 10/05/2020. The introduction of social distancing measures and changes to sexual health clinics in Wales occurred on the week starting 16/03/2020. Two-level logistic regression models were fitted to condomless sex (yes/no) over time, included an indicator for the week starting 16/03/2020, and were extended to explore differential associations by relationship status and sexual health clinic.ResultsData were available from 56 participants and included 697 person-weeks (89% of the maximum number that could have been obtained). On average, 42% of participants reported condomless sex in the period prior to the introduction of social distancing measures and 20% reported condomless sex after (OR=0.16, 95% CI 0.07 to 0.37, p<0.001). There was some evidence to suggest that this association was moderated by relationship status (OR for single participants=0.09, 95% CI 0.06 to 0.23; OR for not single participants=0.46, 95% CI 0.16 to 1.25).ConclusionsThe introduction of social distancing measures and changes to PrEP services across Wales was associated with a marked reduction in reported instances of condomless sexual intercourse among respondents, with a larger reduction in those who were single compared with those who were not. The long-term impact of COVID-19 and associated control measures on this population’s physical and mental health and well-being requires close examination.

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Implementation of a national HIV pre-exposure prophylaxis service is associated with changes in characteristics of people with newly diagnosed HIV: a retrospective cohort study

Sexually Transmitted Infections ◽

10.1136/sextrans-2020-054732 ◽

2021 ◽

pp. sextrans-2020-054732

Author(s):

Ceilidh Grimshaw ◽

Claudia S Estcourt ◽

Rak Nandwani ◽

Alan Yeung ◽

David Henderson ◽

...

Keyword(s):

Sexual Health ◽

Vulnerable Groups ◽

Health Clinic ◽

Post Exposure Prophylaxis ◽

Transmission Route ◽

Newly Diagnosed ◽

Delivery Model ◽

Hiv Prevention Strategies ◽

Prep Implementation ◽

Exposure Prophylaxis

ObjectivesTo review characteristics of individuals newly diagnosed with HIV following implementation of a national pre-exposure prophylaxis (PrEP) programme (comprehensive PrEP services, delivered in sexual health clinics) to inform future delivery and broader HIV prevention strategies.MethodsWe extracted data from national HIV databases (July 2015–June 2018). We compared sociodemographic characteristics of individuals diagnosed in the period before and after PrEP implementation, and determined the proportion of ‘potentially preventable’ infections with the sexual health clinic–based PrEP delivery model used.ResultsThose diagnosed with HIV before PrEP implementation were more likely to be male (342/418, 81.8% vs 142/197, 72.1%, p=0.005), be white indigenous (327/418, 78.2% vs 126/197, 64.0%, p<0.001), report transmission route as sex between men (219/418, 52.4% vs 81/197, 41.1%, p=0.014), and have acquired HIV in the country of the programme (302/418, 72.2% vs 114/197, 57.9% p<0.001) and less likely to report transmission through heterosexual sex (114/418, 27.3% vs 77/197, 39.1%, p=0.002) than after implementation.Pre-implementation, 8.6% (36/418) diagnoses were ‘potentially preventable’ with the PrEP model used. Post-implementation, this was 6.6% (13/197), but higher among those with recently acquired HIV (49/170, 28.8%). Overall, individuals with ‘potentially preventable’ infections were more likely to be male (49/49, 100% vs 435/566, 76.9%, p<0.001), aged <40 years (37/49, 75.5% vs 307/566, 54.2%, p=0.004), report transmission route as sex between men (49/49, 100% vs 251/566, 44.3%, p<0.001), have previously received post-exposure prophylaxis (12/49, 24.5% vs 7/566, 1.2%, p<0.001) and less likely to be black African (0/49, 0% vs 67/566, 11.8%, p=0.010) than those not meeting this definition.ConclusionsThe sexual health clinic–based national PrEP delivery model appeared to best suit men who have sex with men and white indigenous individuals but had limited reach into other key vulnerable groups. Enhanced models of delivery and HIV combination prevention are required to widen access to individuals not benefiting from PrEP at present.

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