Prevention in Focus

Spring 2020 

From the front lines: PrEP program models

Pre-exposure prophylaxis (PrEP) is a highly effective HIV prevention strategy. PrEP can be delivered by a variety of healthcare providers in multiple settings, which can increase the likelihood of reaching diverse populations and communities that may not have easy access to HIV specialists otherwise.

We asked service providers about their innovative approaches to PrEP programs in their communities:

Rachel Loewen Walker, Executive Director, OUTSaskatoon

Why was your program developed? What need was it trying to meet?

We developed our PrEP program because there was a lack of local knowledge and uptake around PrEP among queer people in Saskatoon and area. OUTSaskatoon was approached by a local physician, Dr. Francois Reitz, who wanted to run a PrEP clinic one day a month. Dr. Reitz had seen successful PrEP clinics operating in other cities, particularly in Regina (a city similar in size to Saskatoon). Building on the model in Regina, we saw a great opportunity to launch our own clinic and serve the local community. The clinic was launched right before the Saskatoon Pride Festival in June 2018.

Can you briefly explain how the program works? How do potential clients find out about the program? Who is involved in running the program?

The clinic is a collaboration between two community health centres, OUTSaskatoon and Saskatoon Sexual Health, and is advertised by both organizations. We advertise on social media, on our respective websites, through posters and through word of mouth. We are also in the process of developing advertisements for Grindr and anticipate that this will be a great way to bring more clients into the clinic.

The program runs on the first Saturday of every month out of the OUTSaskatoon clinic with both drop-in and scheduled appointments. Dr. Reitz and Ryan Broom, RN, conduct the assessments, provide prescriptions and review lab work at the clinic. When clients make an appointment to attend a Saturday clinic, they are encouraged to get their lab work completed ahead of time at OUTSaskatoon, Saskatoon Sexual Health, or elsewhere in the city, although this is not required.

OUTSaskatoon’s sexual health coordinator runs the administrative side of the clinic. Saskatoon Sexual Health supports the clinic by processing lab test results and communicating with pharmacies. Together this team ensures that clients are supported before, during and after appointments and appropriately linked to other OUTSaskatoon community programs, as needed. Patients can also access both the OUTSaskatoon clinic and Saskatoon Sexual Health’s regular weekly clinics for all follow-up and blood work.

What successes has the program had? Do you feel that the program has improved access to PrEP in your area? To what do you attribute the program’s success?

The program has been extremely successful, with more than 20 appointments per clinic and more than 60 people starting PrEP in the first year of the program. A large part of the program’s success has been its connection to local community centres. In a physical sense, it is quick and easy for clients to access services as OUTSaskatoon is centrally located, with accessible parking and short waiting times. As well, our clinic is offered in a friendly and welcoming community setting that offers many other programs and services (e.g., education, counselling, social groups, community programs) that may be of interest to clients.

As the first PrEP clinic in Saskatoon, the OUTSaskatoon and Saskatoon Sexual Health clinic has greatly increased access to PrEP in Saskatoon and the surrounding area. It is also worth noting that although we have the full support of the Saskatchewan Health Authority, when we first approached them to start the clinic they proposed a much longer start-up and more complicated procedures. In retrospect, all involved recognize that by running this program through a community centre, we were able to launch the program much more quickly and with a great deal less red tape. This is a huge success of the program and demonstrates the value of collaborative, community-based initiatives.

The PrEP clinic has also served as an example for other physicians and health practices who are interested in prescribing PrEP to their patients. Physicians, nurses and pharmacists have all visited the clinic to learn from the model and get a better sense of how to best serve their patients.

What challenges have you encountered in running this program? Are there any lessons that you would like to share with others who may be thinking about developing similar programs?

One of the greatest challenges the clinic faced early on was ensuring the proper lab work was completed. Not all labs in the city are able to collect all the necessary samples and so making sure that patients know where they can go and what is needed has been critical.

Karen Lundgren, Registered Nurse, Cool Aid Community Health Centre

Jonathan Degenhardt, Health Promotion Educator (formerly), Men’s Wellness, AIDS Vancouver Island

Why was your program developed? What need was it trying to meet?

The PrEP clinic was developed by AIDS Vancouver Island (AVI) and the Cool Aid Community Health Centre (CHC) to address a need identified through the men’s testing clinic. The men’s testing clinic had been running for approximately six years before the introduction of the PrEP clinic. The clinic began officially offering PrEP during the men’s testing clinics in January 2018 just after the British Columbia government started covering PrEP, although the clinic also helped to facilitate access to PrEP before coverage from the BC government for guys who came into the clinic asking for it.

Can you briefly explain how the program works? How do potential clients find out about the program? Who is involved in running the program?

The nurse-led PrEP program happens in conjunction with the men’s testing clinic at the Cool Aid CHC clinic. The Men’s Wellness Coordinator at AVI coordinates the program and advertises through social media platforms that are frequented by the gay, bisexual and other men who have sex with men (gbMSM) community (e.g., Grindr, Scruff, Hustler, Growler, Squirt.org and Facebook).

When someone comes into the clinic they are greeted at the reception desk and are discreetly asked if they are there for testing. The office where the men’s testing clinic operates is also open to clients who are accessing primary care. This provides a layer of anonymity within the clinic: because the space is also used by other clients, no one in the room knows why other people are there.

Most clients interested in PrEP are coming into the clinic and asking for it. Others come in for testing, which provides an opportunity for staff to ask them if they are interested in PrEP. Clients who are interested complete the HIV Incidence Risk Index for Men who have Sex with Men (HIRI-MSM) questionnaire, which assesses risk for HIV among gbMSM. Their HIRI-MSM score is reviewed and they can be connected with a nurse if they meet the criteria that qualifies them for PrEP (as stated by provincial guidelines). Clients can be seen the same day by a nurse to discuss PrEP, often within 10–15 minutes.

During their initial visit to the clinic, a nurse completes the blood work, screening for sexually transmitted infections and urine specimen collection required to get PrEP covered by the province. Nurses also provide education on adherence and safer sex. Nurses share test results with a clinic physician who writes a prescription for PrEP, which is faxed to the BC Centre for Disease Control (BCCDC). The BCCDC sends the medication to the Cool Aid CHC clinic. If a client’s blood work indicates an issue, they are scheduled to see one of the physicians at the clinic. If clients do not have a family doctor, they fill out an intake form so they can become a patient of the Cool Aid CHC clinic.

Clients visit the Cool Aid CHC clinic every three months for follow-up testing and a new PrEP prescription. Every three months the physician signs off on a new prescription, the prescription is faxed to the BCCDC and medications are delivered to the clinic.

What successes has the program had? Do you feel that the program has improved access to PrEP in your area? To what do you attribute the program’s success?

The clinic has grown to become one of the largest PrEP clinics in the province and has seen zero seroconversions in PrEP clients. So far, 182 people have enrolled in the program.

The success of the program can be attributed to many things:

  • Online interactions (e.g., on social media platforms), as well as word of mouth, have contributed to the success of bringing people into the clinic. We established a presence among gbMSM: they know and trust the clinic as a place to get testing and to access information.
  • The integration of the PrEP clinic into the men’s testing clinic, which had already been in operation for six years, raised awareness in the community. The clinic provides a low-barrier and stigma-free approach.
  • The timing of the opening of the PrEP clinic occurred less than a week after it was announced that PrEP would be free for at-risk gbMSM in BC.
  • There is an effective partnership between AVI, the Cool Aid CHC and other community partners who support the work.
  • The PrEP clinic has been able to adapt its programming to meet the needs of the folks who access its services the most.

What challenges have you encountered in running this program? Are there any lessons that you would like to share with others who may be thinking about developing similar programs?

Funding for the PrEP clinic has been a challenge. When the program started, there was no additional funding available and nurses were staffing the PrEP clinic on top of their regular workloads. The increase to workloads was a challenge.

Another challenge was the location of the PrEP clinic, which is in the same building as a safer consumption site. There were issues with gbMSM not being comfortable accessing the space because of the other clientele who access services there. This was primarily due to stigma, and it is an ongoing issue. We do our best to educate the folks who access the clinic, and if they just are not comfortable accessing the space, they are informed about other local resources that might better suit their needs.

The most important lessons are to be patient, to be flexible and to listen to the needs of your community. It may be slow to start, but once the word gets out that your site is a safer place for sexual healthcare, it will get busier. Lastly, listen to the people who are accessing your services, find out what apps they are using, find out what clinic hours will work for them and use what works best for them!

Matthew Harding, Community Programs Manager, MAX Ottawa

Samuel Gauthier, Speaker, Between Men program, Le BRAS Outaouais

Why was it necessary to develop a program to improve access to PrEP in your area?

After hearing from certain health service users, it became clear to us that the routes of access in our area were not very coordinated. Some clinicians saw patients within a week of referral, while others had a two-month waiting list. We knew there was an opportunity to develop a strategy to coordinate services at the regional level so that people who need quick access can get it and avoid the bottlenecks in health services.

Initially, the work consisted of mapping the available services and increasing communication between healthcare providers. However, when we gathered all the partners around a table for a first meeting, we realized that there were many other barriers to accessing PrEP. We knew that these barriers would require regional leadership and coordination (e.g., building healthcare providers’ capacity; developing healthcare providers cultural skills; addressing the cost of PrEP, which is still a barrier for many; increasing the level of information available). Since then, we have been working with healthcare providers, community workers, pharmacists and public health workers. With this multidisciplinary team, we can more easily target the barriers to accessing PrEP and try to reduce them within the next two years.

Can you briefly explain how the program works? Who is involved in managing the program?

The strategy will take aim at reducing the above-mentioned barriers. As part of the strategy, innovative measures will be put in place over a two-year period. For example, in the fall of 2019, we launched the Équip Toi campaign on the Internet, through social media and with promotional items, such as condom pouches and pill organizers. This initiative will address the lack of local messages specific to access to PEP and PrEP in our area.

Another measure that has been developed is the PrEP navigation service, a program to help people navigate the uncoordinated access routes to PEP and PrEP that currently exist in our area.

What successes has the program had? Do you feel that the program has improved access to PrEP in your area? To what do you attribute the program’s success?

The strategy will be adopted in 2020. At that time, we will start assessing the impact of the measures to ascertain the strategy’s results. Already, more than 1000 people have visited our website and more than 30 people have been referred to a health professional to obtain PrEP or PEP.

What challenges did you encounter when implementing this program? Are there any lessons you would like to share with others who might consider developing similar programs?

The National Capital Region (Ottawa-Gatineau) straddles two provinces and therefore two sometimes very different healthcare systems. The need to coordinate partners from different healthcare systems definitely contributed to the complexity of the process. In addition, PrEP-related costs differ in the two provinces. The Ontario and Quebec public drug insurance plans do not cover PrEP to the same extent. The same goes for the access routes for obtaining PrEP and PEP.

As well, Ottawa-Gatineau’s bilingual status has been a major issue in developing the strategy. It is important that all the information be available in both languages and that the navigation service be completely bilingual. Having partners like BRAS Outaouais has enabled us to offer services in French with providers who are familiar with the access points for PrEP and PEP in the Outaouais region. In closing, the message we would like to leave with those who might want to initiate such a project is that patience and lots of flexibility – as well as sufficient funding (!) – are needed to bring a project like this to fruition.

Related article

For more detailed information on PrEP programs, see Overcoming barriers to PrEP: Program models using diverse settings and providers.