The Quest for PrEP
Summary
Quest Community Health Centre (Quest) is a non-profit registered charitable organization providing primary health care, health promotion, and community capacity building to residents of St. Catharines and the Niagara Region. Quest serves a wide range of priority populations that face increased barriers to accessing healthcare. An emphasis is placed on those individuals experiencing: mental health; addictions or concurrent disorders; street-involved populations (homeless, under-housed, sex trade workers); isolated seniors; at-risk children, youth and families; individuals who frequent the Emergency Department for care/opioid-dependence (USAT); Migrant Agricultural Workers (MAWP); as well as sexually and gender diverse populations (LGBTQ+).
Quest’s mission is to provide client centered holistic health care to those individuals experiencing social, economic and cultural barriers. Due to individual and social factors, many of these populations seen at Quest face an increased risk of disease, including HIV infection. Through gap analysis, it was found that there was room to expand Quest services in the area of HIV prevention. Currently, there is an important prevention medication that has been approved for use in Canada. Pre-exposure prophylaxis (PrEP) refers to the daily use of prescription antiretroviral medication by people who are HIV negative in order to prevent transmission from HIV positive individuals. Completion of this Fellowship would ensure all Quest nurse practitioners (NP) and medical doctors (MD) knowledgeable and comfortable in providing PrEP prescriptions to interested and eligible clients. All registered nurses (RN) and registered practical nurses (RPN) would be trained as PrEP experts and work collaboratively with NP/MDs to increase continuity of care providing ease of access to Quest clients. All remaining allied health staff will have increased comfort in providing clients with information on PrEP, and how to access this service at Quest.
The overall goal of this fellowship was to provide myself with the knowledge and expertise to become a champion for PrEP amongst Quest’s interdisciplinary team, and implement organizational supports and standards of care that will lead to the reduction in barriers to health by ultimately providing access to PrEP to at-risk clients. In order to achieve this goal, I began by educating myself on safe sex practices, individual risk behaviours, HIV basics and prevention strategies, as well as safe injection drug use. I was then able to develop a firm understanding of the PrEP medication, tenofovir disoproxil fumarate/emtricitabine, and prescribing guidelines with the use of the product monograph and the Canadian Guidelines on HIV PrEP. My knowledge and skills in facilitating PrEP prescribing were further enhanced through the shadowing of the London Regional HIV/AIDS Connection PrEP Clinic Nurse Practitioner. I now feel confident in educating and counselling clients on HIV prevention and safe sex/drug use practices as well as working together in assessing HIV risk, ordering appropriate lab work, and monitoring suitability for the continuation of PrEP.
Outcomes
Quest client outcomes include improved awareness that there is indeed a medication that can prevent HIV, as well as improved access to information explaining what PrEP is and how it works. This was achieved with the use of posters in exam rooms and common spaces. These posters provide information on who should consider using PrEP, and where to get more information. The posters also provide visibility on the subject of HIV prevention and hopefully reduce the stigma and fear of asking their provider questions about prevention options available to them. The plan for PrEP prescribing at Quest included the education of all staff, and not just primary care. Therefore clients have the ability to speak to whichever staff member they feel most comfortable with, eliminating barriers to accessing this medication. The process for obtaining a prescription was developed in order to make access simple for clients. Initial appointments are booked with an RN/RPN as they have improved accessibility and are able to spend more time with clients. Clients will have the opportunity to learn and ask questions during this appointment, and then make an educated decision as to whether PrEP is the right choice for them. If they decide to move forward, processes are in place to facilitate this. If they decide that this medication is not right for them, they will have
been provided with important sexual health information that can hopefully lead to safer sex practices. Clients who start taking PrEP will be monitored every three months including screening for sexually transmitted infections (STI). More regular screening for clients who are already considered high risk can help to increase STI diagnoses and lead to more rapid treatments thereby helping to reduce the possibility of transmission and STI incidence long term (Jenness et al., 2017).
Prior to the start of this Fellowship, only one out of six Quest NP/MDs reported ever prescribing PrEP in the past. Out of those who had not prescribed PrEP, 100% reported their knowledge of PrEP medication, prescribing parameters, indications for use, assessment and follow-up as being nil to moderate and 67% did not feel comfortable prescribing without further education. Following NP/MD education/training provided by the nurse fellow, 100% reported they felt their knowledge and understanding of PrEP was high, and now felt comfortable in prescribing to clients.
Prior to allied health staff training, 100% of staff reported no knowledge to moderate knowledge of PrEP medication; 82% reported they had low to moderate understanding of who would be eligible for PrEP; and 73% of staff did not feel comfortable in discussing PrEP with their clients. Following staff education, 100% now reported their knowledge of PrEP; understanding of who would be appropriate for PrEP and comfort in providing information to clients was moderate to high. The development of the PrEP prescribing program at Quest was completed with a multidisciplinary approach in mind. Therefore, all staff is now aware of and have access to resources aimed at improving provider knowledge as well as a wide range of educational resources for clients.
Overall experience
Overall, I found the fellowship to be an excellent opportunity to enhance my knowledge and skills as a registered nurse. This was accomplished by increasing my knowledge in HIV prevention, safe drug practices and sexual health. I also enjoyed the
chance to work collaboratively with Quest’s multidisciplinary team as well as learn from experts in the field outside of Quest. The fellowship provided me with the ability to develop my leadership, presentation and communication skills through the education of all staff, presentations in staff meetings, updates to the Board of Directors and development of new program materials including intake forms, information for clients and medical directives. Taking what I have learned and developing programming in line with Quest’s mission of reducing barriers to health and increasing client knowledge and awareness was very rewarding. I look forward to continuing to improve upon this program utilizing the sustainability plan, using future opportunities to collaborate and network with other organizations and becoming a strong advocate for those who would benefit from PrEP.
References
Jenness SM, Weiss KM, Goodreau SM, Gift T, Chesson H, Hoover KW, Smith DK, Liu AY, Sullivan PS, Rosenberg ES. Incidence of gonorrhea and chlamydia following human immunodeficiency virus preexposure prophylaxis among men who have sex with men: a modeling study. Clinical Infectious Diseases. 2017 May 13;65(5):712-8.
