The Maple Leaf PrEP Clinic

What is the Program?

The Maple Leaf Pre-exposure Prophylaxis (PrEP) Clinic is a nurse-led PrEP clinic with the goal of facilitating access to PrEP for those at risk of acquiring HIV. The clinic also provides community resource referrals, routine sexually transmitted infection (STI) testing and assistance with health system navigation (i.e., guiding, connecting or accompanying people to health and social supports with the goal of having clients manage their own care).

The PrEP Clinic is a branch of the Maple Leaf medical building in Toronto and is funded jointly through partnerships between the Maple Leaf Medical Clinic, individual physicians and the Ontario HIV Treatment Network (OHTN).

Why Was the Program Developed?

The Maple Leaf PrEP Clinic was created to improve access to PrEP for those at risk of HIV infection (e.g., gay, bisexual and other men who have sex with men [gbMSM], sex workers, people in serodiscordant relationships, people experiencing intimate partner violence, people who inject drugs). The nurse-led model is based on similar nurse-led models that have been used in other areas of healthcare (e.g., diabetes care).

The PrEP clinic’s philosophy is that PrEP represents an empowering step for people to take charge of their sexual health and that PrEP should be accessible regardless of access to public or private insurance. Much work is done at the clinic to help individuals access PrEP who are not covered by insurance and otherwise would not be able to afford the treatment (e.g., connecting people to publicly covered drug programs).

How Does the Program Work?

The nurse-led Maple Leaf PrEP Clinic is embedded in the Maple Leaf Medical Clinic, a multispecialty clinic providing health care in Toronto, and was opened in June 2018. The PrEP clinic has two exam rooms and a waiting room. Operating hours are Monday to Friday from 10:00 am to 6:00 pm.

Waiting room at the Maple Leaf PrEP Clinic

A clinic coordinator, who is also a registered nurse, coordinates the PrEP clinic. Clinic coordinator duties include performing outreach with organizations that could potentially refer clients to the clinic (e.g., sexual health clinics, HIV service organizations, community pharmacies, family doctors’ offices) to make them aware of the services provided and performing outreach and PrEP education for physicians who are interested in learning more about prescribing PrEP to their patients. The clinic coordinator also functions as the clinic nurse. Nursing duties include client intake/assessment, completion of initial and follow-up STI and other required tests (e.g., kidney function tests) and provision of PrEP prescriptions at three-month intervals under a medical directive.

Clients are connected to the clinic through community organizations (e.g., drop-in centres, HIV service organizations) and medical clinics or through self-referral by phone, email or walk-in. The clinic provides both daily and on-demand PrEP to clients (but not post-exposure prophylaxis). The clinic also works to make PrEP affordable through programs tailored to people lacking coverage through private insurance; for example, it links people to publicly funded programs (e.g., the Trillium Drug Program in Ontario). The clinic also informs people of other options, as appropriate (e.g., purchasing PrEP from outside of Canada).

The PrEP clinic operates through use of a medical directive that allows the clinic nurse to work with an expanded scope of practice, which includes managing the testing and treatment of STIs, testing for HIV, immunizing patients against human papillomavirus and hepatitis A and B and doing baseline and follow-up kidney function testing for PrEP patients.

When a client arrives at the clinic for the first time, there is an initial consultation with the clinic nurse. An intake form is completed, which includes a sexual history (e.g., use of condoms, past STI diagnosis) to determine HIV risk, in addition to an in-depth discussion about PrEP and sexual health. The clinic nurse discusses the risk assessment and, in very rare cases where the client’s risk profile is extremely low, may make a recommendation against PrEP. However, the vast majority of people who present for PrEP initiate it. During the initial consultation, blood and urine tests and swabs are completed to screen for HIV and other STIs, and tests are done to determine kidney function. An appointment is made with a clinic physician one to two weeks following the initial intake consultation.

Physicians review initial blood and urine test results and if any STI tests come back positive following the initial intake/assessment appointment, the client can return to the clinic and be treated by the clinic nurse prior to their initial appointment with a clinic physician. If the client is HIV negative, the clinic physician can issue the first prescription for three months of PrEP during their appointment with the client. After a prescription is initiated by a physician, it is renewed during quarterly follow-up appointments by the clinic nurse (working under medical directive). If the client is found to be HIV positive at intake, they are referred to an HIV physician on the same day to begin treatment.

Waiting room at the Maple Leaf PrEP Clinic

Clients return to the clinic one month after starting PrEP to meet with the clinic nurse and ensure that there are no issues (e.g., adherence issues, medication side effects, problems with cost). The visit normally includes an HIV and kidney function test, but not testing for all STIs unless clients indicate a need for testing. After the one-month check-in, follow-up appointments take place quarterly. At these appointments, clients check in with the nurse and receive adherence counselling, community resource referrals, sexual health counselling and blood/urine tests for STI screening and kidney function (i.e., creatinine). The clinic nurse and/or clinic physicians review tests. During these appointments, the clinic nurse provides PrEP prescriptions previously completed by the clinic physician.

If anything comes up between appointments (e.g., a suspected STI or suspected HIV infection, medication side effects), clients can book a same-day appointment with the clinic nurse.

An administrative staff person books appointments, does data entry, responds to email and phone inquiries, assists with ordering supplies and completing monthly budgets, coordinates meetings between providers and is usually the first point of contact for patients when they enter the clinic.

Required Resources

• Full-time registered nurse/clinic coordinator
• Full-time administrative staff person
• Physicians with clinical hours on select days and on-call availability, as needed
• A medical directive that allows the registered nurse to practise with an expanded scope (e.g., management and treatment of STIs, immunizing patients against human papillomavirus and hepatitis A and B, doing baseline and follow-up kidney function testing for PrEP patients)
• A space to provide testing, counselling and clinical exams

Challenges

• Some people who stand to benefit from PrEP can be difficult to reach because of issues related to not having a fixed address or contact information. It can also be difficult to keep people engaged in care (e.g., attending follow-up appointments where they would receive adherence counselling). This is an ongoing challenge that must be addressed across HIV prevention and treatment programs.
• The cost of PrEP is a potential barrier. The cost is approximately $260/month. This may be covered partially by a provincial drug program or by private insurance. The clinic works with individuals to find solutions, such as linking people to the Trillium Drug Program in Ontario and/or helping them to navigate their insurance. The clinic also informs people of other options, as appropriate (e.g., purchasing PrEP from online suppliers located outside of Canada).
• The clinic largely reaches gbMSM; ongoing outreach to non-gbMSM clients has been challenging. Reaching other populations, for example people who inject drugs, can be difficult because of the stigma experienced by this population when accessing health services. The clinic plans to focus on outreach to non-gbMSM populations in 2020 by targeting community-based organizations that serve other populations (e.g., sex workers, people in serodiscordant relationships, women, people who inject drugs).

Evaluation

• Since it opened in June 2018 until November 2019, the PrEP clinic has prescribed PrEP to approximately 1300 patients.
• From June 2018 to November 2019 the clinic has facilitated financial access to PrEP for over 500 patients.

Lessons Learned

• Have an idea of the indicators that you will need to track for reporting purposes before the start of the program and ensure that you have an appropriate means to collect data. It can be challenging to establish a system to collect data, especially if it requires determining the data retroactively. Have a plan.

Program Materials

• New Client Intake Form
• Maple Leaf PrEP Clinic Consent to use Email and Electronic Communication
• Maple Leaf PrEP Clinic Promotional Flyer

Contact Information

Nick Tsergas, RN
Clinic Lead
Maple Leaf PrEP Clinic
14 College Street, Suite 102
Toronto ON  M5G 1K2
Tel: 416-920-1991
Fax: 1-888-819-7892
Email: ntsergas@mlmedical.com