Integrating PrEP into a LHD STI Clinic

State: IL Type: Promising Practice Year: 2017

Champaign-Urbana Public Health District (CUPHD), accredited by the Public Health Accreditation Board (PHAB) in 2014, is the local public health authority for the Cities of Champaign and Urbana and Champaign County, Illinois. Champaign County is located in east central Illinois and is 998.39 square miles with a population density of 201.8 people per square mile. Champaign County is an exemplar micro-urban community and a statewide leader in progressive education, health care, government, high technology, light industry and agriculture. In 2015, the US Census Bureau estimated the population to be 208,861 residents. The current population of Champaign County is composed of 74.5% Caucasian, 12.8% African American and 9.6% Asian (2013 U.S. Census Bureau estimate). The percentage of Hispanic residents in Champaign County in 2013 was 5.1%. Public Health Issue: HIV/AIDS is a significant public health issue in the United States. The Centers for Disease Control and Prevention (CDC) estimates that 1.2 million people aged 13 years old and older are now living with HIV infection, and an additional 40,000 new HIV infections occur every year. One out of eight people with HIV are unaware of their infection. Pre-Exposure Prophylaxis (PrEP) is a very effective tool in preventing new HIV infections. PrEP is a biomedical intervention that allows an HIV negative person to take a daily medication (Truvada) which is over 92% effective in preventing a new HIV infection. When a person on PrEP is exposed to HIV through sex or injection drug use, the medication keeps the virus from establishing an infection in that person. CUPHD has implemented a PrEP program to engage clients at increased risk of HIV in this intervention. The program has been integrated into the existing CUPHD STI Clinic. PrEP is an important addition to the existing HIV prevention activities provided at CUPHD. Goal: Zero New HIV infections in Champaign County Objective: All clients accessing STI or HIV services at CUPHD should have timely access to PrEP while they are at the CUPHD. Objective: Increase local provider network of PrEP prescribers Objective: Increase community awareness of PrEP as a tool to prevent HIV infection. Practice Implementation: In June 2015, CUPHD implemented a PrEP Program into the existing HIV and STI structure. Clients who attend the STI clinic and report an increased risk for HIV transmission (MSM, IDU, and persons with HIV positive partners) receive education on the benefits of PrEP. Clients who are interested in this biomedical intervention have the opportunity to receive a prescription for Truvada that same day. An HIV services staff member is assigned to assist this client in accessing this medication, engaging medication and co-pay assistance programs, and completing the required follow up services. Outcomes: Between June 2015 and October 2016, a CUPHD provider has given 92 Truvada prescriptions for PrEP. 73% have adhered and have attended their last required appointment at CUPHD for PrEP management. 12% of clients have relocated to a new city, most with a referral to another clinic for PrEP continuation. 27% clients are lost to follow up” and have not completed their last required appointments for PrEP. PrEP case managers attempt to make contact with all clients who discontinue PrEP without explanation to re-engage them in the program. Were Objectives Met? Yes. 73% of all clients prescribed PrEP have continued on the regimen. This is a great success rate in the first year of program implementation. What led to success? Integration and Accessibility. Partnership with Collaborators like Walgreens for Drugs. Public Health Impact: The National HIV/AIDS Strategy for the United States: Updated to 2020” included a new developmental indicator to increase use of pre-exposure prophylaxis (PrEP) by 500 percent” to further strengthen the response to HIV in the 2016 Progress Report. The CUPHD intervention is on target to meet this goal. Website : Facebook @CUatZERO
CUPHD shares the CDC's goal of creating a future free of HIV. There are tremendous disparities in HIV prevalence. Men who have sex with men bear a greater burden of HIV, accounting for about 63% of all new infections. The estimated number of new HIV infections was greatest among young MSM, specifically young African American MSM. Public health nurses and HIV services staff are trained to provide STI, HIV, and family planning services for all clients at each visit. The guiding principle is to provide needed services during the client's visit rather than referring a client to return for another service at CUPHD. The CDC developed High-Impact HIV Prevention: CDC's Approach to Reducing HIV Infections in the United States” as a roadmap to eliminate HIV. This guidance documents the plan that CUPHD has adopted for its HIV prevention program. CUPHD has employed the following HIV prevention activities: Biomedical Interventions; Public Health Strategies; Behavioral Interventions; Structural Interventions; and Social Marketing. Biomedical interventions include access to Pre-Exposure Prophylaxis (PrEP) to clients most at risk for HIV infection. This is a powerful tool in HIV prevention and even more effective when combined with other prevention strategies. PrEP was approved for use to prevent HIV infections in 2012. In 2014, the CDC released the PrEP Clinical Practice Guidelines to describe what providers need to know to implement PrEP. Other biomedical interventions focus on treatment adherence strategies for persons living with HIV. CUPHD staff and peers work closely with clients to ensure that they attend medical appointments and in assessing potential barriers to medication adherence. STI testing is promoted for all persons at risk including people living with HIV. CUPHD provides STI services onsite all day each weekday. In addition, CUPHD has an offsite evening clinic one night a week for clients who cannot access services at the main clinic. STI testing is offered in all mobile outreach and during gay bar outreach. STI testing is normalized during routine visits for HIV care services. CUPHD provides public health strategies which include HIV testing and linkage to care for persons that are HIV positive. Staff has received intensive, focused training to conduct HIV Counseling and Testing with those at risk for HIV. Staff is practiced at delivering an HIV positive test result and conducting partner services. Linkage to Care interventions are highlighted with the engagement of HIV persons in medical care and supportive services. Behavioral Interventions at CUPHD include a long-standing Mpowerment project for African American MSM. This group follows the CDC Effective Behavioral Intervention model and is managed by two peers who are employed by CUPHD. The peers are IDPH trained to conduct HIV Counseling and Testing. The project uses an offsite location for project activities. The peers have been trained in PrEP promotion and market the CUPHD PrEP clinic through their gay bar outreach and small group activities. Peers are integrated into the CUPHD HIV services programming Another behavioral intervention that is important to the program is peer support for persons living with HIV. CUPHD employs four HIV positive peers that provide treatment adherence strategies to clients accessing care services. Peers engage members of their social networks to reach harder-to-reach” clients and connect them to medical care. The peers assist HIV positive persons with accessing medical appointments, laboratory testing and other health services that are needed to manage HIV disease. Peers engage these members in AIDS Drug Assistance Program (ADAP) enrollment to ensure medication adherence. Other barriers to medical care are assessed though one on one meetings and in support groups. These peers are a vital piece of the care continuum and reach HIV positive persons in ways that local health department staff cannot. CUPHD operates with the understanding that all HIV programming must be supported by structural interventions including syringe exchange and condom distribution. CUPHD has provided syringe exchange services since 2001. CUPHD offers comprehensive harm reduction services to participants. Sharps containers are offered to all participating clients. Participants who are hesitant to take a sharps container are offered a hard plastic container, often bleach or laundry detergent bottle, for collecting syringes. In addition, CUPHD provides overdose prevention services. Participants are trained in the signs and symptoms of opiate overdose and in rescue breathing. The overdose training includes Naloxone administration, how to continually monitor the overdosing person, and how to contact emergency services. Condoms are distributed throughout the agency, through mobile outreach, and at the gay bar. Access to condoms is vital in reducing new HIV infections. CUPHD works to ensure that people living with HIV or who have an increased risk for HIV infection have easy access to condoms as a prevention tool. Efforts to identify HIV positive individuals who are aware of their status but not engaged in HIV medical care has become a priority. Research has shown that engaging HIV positive persons in medical care reduces HIV transmission potential through HIV viral suppression. This staff conducts surveillance activities for persons who are previously diagnosed with HIV but are not active in HIV medical care. The Illinois Department of Public Health (IDPH) generates a roster of persons who are HIV positive but have not had viral load testing in the past six months or have been recently diagnosed with an STI. CUPHD staff conducts DIS investigations to locate these individuals and assist them in addressing their barriers to accessing HIV medical care. This surveillance model has been implemented in the local HIV clinic. The HIV clinic now releases a roster of clients that are not medically-adherent for the same surveillance activities. Staff has discovered that it is easier to locate a client who missed a recent HIV related medical appointment rather than wait until the client is reported by IDPH months later. This collaboration has enhanced the quality of care that clients receive. CUPHD has adopted the national social marketing campaign, Getting to Zero” by putting a local spin on it with CU at Zero”. The campaign has three tenets: Zero new HIV infections; Zero HIV related deaths; and Zero HIV-related stigma. The campaign is particularly useful because it fits well with CUPHD's integrated services model, as it engages both HIV positive and negative individuals. CU at Zero” incorporates all of the interventions that are employed at CUPHD to end HIV in our community. Messaging under the CU at Zero” brand can range from promoting condom use, to PrEP and HIV testing, to treatment adherence, and STI testing for HIV+ people. The campaign differs from traditional use a condom every time” campaigns, and parallels efforts happening in larger cities.
HIV in the U.S.
CUPHD has a long standing history of collaborating with traditional and non-traditional partners for new and existing program implementation. In order to assess the need for PrEP interventions in Champaign-Urbana, CUPHD gathered stakeholders including consumers and representatives from the University of Illinois, the local AIDS Service Organization, Walgreens HIV Specialty Pharmacy, and the local medical group in June 2014. This group met to discuss PrEP and local options for engaging clients in PrEP interventions. The group developed plans to engage medical provider in PrEP promotion with patients and intervention delivery. A client survey was also developed to determine client awareness and interest in PrEP promotion. In the summer and fall of 2014, CUPHD HIV services staff was focused on PrEP promotion and working with local providers to build PrEP prescribing capacity. The plan from the stakeholder's meeting was to refer CUPHD clients to local providers for PrEP prescription. In October 2014, the local medical group decided to refer all PrEP requests to their infectious disease physicians. This created a significant barrier to PrEP delivery for clients, thus creating a need for a new model of PrEP delivery in Champaign-Urbana. Client requests made to CUPHD staff for PrEP resources increased over the next several months. It was at this point that the CUPHD management team agreed to pursue the creation of a PrEP clinic through existing HIV and STI services. In June 2015, CUPHD's HIV services staff received extensive training on PrEP from the AIDS Foundation of Chicago and the Illinois Department of Public Health. After this training, CUPHD implemented PrEP services into the existing HIV/STI comprehensive clinic. A PrEP client receives comprehensive STI services, including site-specific testing for gonorrhea and Chlamydia, syphilis and fourth generation HIV testing. During the initial PrEP visit, each client receives a personalized risk assessment, counseling on the importance of medication adherence, and education on the potential side effects of Truvada. Laboratory screening for Hepatitis B and creatinine clearance for kidney function is completed. The CUPHD provider completes an acute HIV signs and symptoms review and a provider/client agreement to initiate a prescription for Truvada. HIV services staff works with clients to ensure that they have the ability to pay for medication, through health insurance, Medicaid, or the pharmaceutical medication assistance programs. The client leaves the visit with a prescription for Truvada, a plan to pay for the medication, and an appointment for a follow up visit with their assigned PrEP case manager. CUPHD staff works closely with the Walgreens pharmacist. The pharmacist assists CUPHD in completing medication assistance forms for clients, when needed. He contacts CUPHD when a client is due to pick up their medication but have not made contact. The pharmacist also works with local providers to ensure that all required PrEP related testing is completed and will refer providers to CUPHD for support. Start-up cost Minimal start-up costs were associated with the addition of this intervention. Staff time was the main resource needed to start this clinic. Existing staff was incorporated into this new model of care. Existing grant funds were used to develop the staff skills needed for this program. Staff spent approximately 20 hours in onsite training to provide PrEP services. The CUPHD HIV services manager spent close to 100 hours preparing for the clinic by completing PrEP paperwork, clinic flow plan, getting CUPHD management and provider buy-in, collaborating with Walgreens, working with laboratory personnel to add new testing options, and in preparing marketing materials for PrEP. HIV services staff already had the skill set needed to effectively deliver this intervention: HIV risk assessment; HIV Test Counseling; medication adherence counseling; financial assistance navigation; and expanded Medicaid and insurance enrollment. HIV services staff was already integrated into the STI clinic and have provided client-based HIV services to STI clinic clients for the past four years. All STI and HIV staff are crossed trained to deliver PrEP interventions. Staff time spent on PrEP related activities is charged to the HIV prevention grant that is managed by IDPH. Laboratory services were added for PrEP implantation. CUPHD obtained lab support from a private lab to conduct PrEP specific testing. The costs for these tests are covered by the client's insurance and the HIV prevention grant as a payer of last resort. The intention was to keep this intervention at a low cost and sustainable to be able to replicate it to other communities. We do not anticipate any additional on-going cost to this program. There were no indirect costs associated with the implementation of the PrEP program.
CUPHD conducted a community survey on knowledge and attitudes toward the PrEP Intervention in September 2014 during the Champaign-Urbana gay pride weekend. Survey results indicated that most clients did not know about PrEP, over half had never heard of it, but nearly 70% of those surveyed said that they would consider the intervention with what they knew of it. We also learned that one quarter of the persons surveyed would not feel comfortable talking to their provider about starting PrEP. Process Evaluation: The CUPHD HIV services program manager reviews PrEP client charts monthly to ensure that all required testing and follow up visits have been conducted. An Excel spreadsheet is maintained to track client engagement and retention in PrEP services. The intervention is now added to the CUPHD EHR. Clients who completed the last scheduled PrEP appointment are considered to be current in the program. The CUPHD nursing staff keeps a log on the clients that have been engaged in PrEP education but do not choose this intervention at the time of the STI clinic visit. Clients are given information sheets with national resources to education themselves on PrEP and are encouraged to return if they decide to discuss the PrEP intervention further. HIV services staff meets weekly to discuss HIV interventions, including PrEP. The PrEP program manager, STI clinic nurse who is the lead on PrEP, providers, and the HIV services program manager meet monthly to discuss program needs and challenges. Client feedback on the CUPHD PrEP intervention is discussed at these meetings and improvements are made based on these suggestions. For instance, clients reported a desire for appointment reminders and CUPHD developed the case management model to address this concern. Outcome Evaluation: Between June 2015 and October 2016, a CUPHD provider has given 92 Truvada prescriptions for PrEP. 73% of these clients have attended their last required appointment at CUPHD for PrEP management. This is a great response to a new program in the first year of its implementation.
Many lessons have been learned as this program continues to develop. The need for prescription on demand” was recognized in the first months of the program. CUPHD committed to training a nurse practitioner who is on site daily to serve as a PrEP provider. This change led to more engagement in the program. STI nurses have been crucial to the success of this program and act as gatekeepers into the PrEP program as they encounter clients at increased risk of HIV infection in STI clinic. If IDPH funding were eliminated, CUPHD will be able to sustain PrEP activities funded through private insurance and Medicaid billing infrastructure that CUPHD has developed and build over the years. CUPHD staff would employ the National Alliance of State and Territorial AIDS Directors (NASTAD) guidance document Billing Coding Guide for HIV Prevention: PrEP, Screening, and Linkage Services”. It is predicted that these billable services will cover over 75% of the costs associated with PrEP interventions. The additional costs will be supplemented with local agency tax dollars as the benefits outweigh the risk of doing nothing. CUPHD sponsored a PrEP training for providers at a local medical group. The training was well attended with over 75 providers in attendance. CUPHD will continue to build community capacity with medical providers to expand PrEP access.
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