Should your clinic offer PrEP? Course review Day 23 of 42.
Should your clinic offer PrEP, pre-exposure HIV prophylaxis?
Demetre Daskalakis, the Assistant Commissioner for the Bureau of HIV AIDS Prevention and Control in the New York City Department of Health and Mental Hygiene, spoke about the current approaches in the US to the issue of expanding access to PrEP.
The lesson will be of interest to social workers from the field of sexual health and HIV prevention and health organisers. Dr Dakalaskis will set an example of successful social worker initiatives when people were able to develop and implement PrEP programs in some US cities.
So, the analysis of epidemiological data allows identifying the geographic areas vulnerable to HIV and there to concentrate the efforts of preventive programs. The US Centers for Disease Control and Prevention (CDC) periodically updates the epidemiological maps. Such data sources in other countries could be provided by governmental organisations or not-for-profit organisations working in the field of open data. Demeter advises activists to monitor such information.
In the US, such data also contains demographic information — how the risk of HIV transmission is distributed among people by sex, ethnicity, age, and level of education. So, the maximum risk of getting HIV in the US is observed among black women and women of Hispanic origin.
1 in 4 sexually active HIV-negative adult men who have sex with men was postulated to have indications for PrEP.
Another article from the CDC by Don Smith estimated this denominator, mentioning 1 in 4 sexually active HIV-negative adult men who have sex with men was postulated to have indications for PrEP. An estimated 1 in 200 HIV-negative heterosexually active adults have indications for PrEP, which means that overall, an estimated 1.23 million adults in the United States have substantial risk for acquiring HIV and therefore may be PrEP candidates.
In clinics of sexual health, the situation is even more attractive: one of the 42 men who have sex with men (MSM) who visited sexual health clinics for any reason, was diagnosed with HIV within one year of the visit. Among those who had syphilis during such a visit, HIV was in one of 20 people in the next year. If on the first visit, chlamydia or gonorrhoea were found, one in 15 of these men risked getting HIV within a year. Such findings help to target the offer of preventive programs.
Resources are needed for starting a social program and therefore Demeter proposes to determine the source of resources - funding, available clinics, opportunities for media advertising campaigns involving participants. You can adopt the experience of PrEP programs in New York to implement it in your city, in your country, taking local specifics into account. It is interesting that the rules of the New York PrEP program do not oblige each clinic to have an HIV specialist in the staff - it is enough only for medical personnel and to have an established telemedicine connection with the infectious disease doctor. Such an approach reduces the cost of programs but requires compliance with the requirements of local telemedicine laws.
It’s important to draw flowcharts, understand how people will become aware of the program, how to keep people involved in the program over time. This requires experience in the design work, says Demeter, “Everyone wants to run PrEP yesterday, but it’s important to work out the details of the program before the start.”
An example of a successful launch is the One Stop NYC project — a centre for pre-exposure (PrEP) and post-exposure (PEP) HIV prevention, HIV testing and help for those who learn about their HIV-positive status.
Here is an example of a real scenario from the life of One Stop NYC:
The man appeared to the clinic of sexual health; he was diagnosed with rectal gonorrhoea and chlamydia. Since the man is at substantial risk of HIV transmission, he has to be offered pre-exposure prophylaxis, PrEP. If he agrees and blood tests allow him to initiate PrEP — the social worker will have to study the possibilities of financing PrEP and advising on the program. It is important that the social worker has, at the time of the consultation, comprehensive information on the current health insurance programs and co-financing of the PrEP.
Dr Daskalaskis also says that many private clinics were involved in the One Stop NYC project, the selection was data-driven, based on an analysis of epidemiological data. Clinics were chosen in areas where the level of HIV transmission was higher than the city average. The city administration helped with launching the program, and now on the official site of New York nyc.gov you can find PrEP and PEP in your neighbourhood. The project was also supported by an online and offline advertising campaign.
In addition, the organizers of the program have developed a Play Sure Kit — a convenient small box, which is equipped with condoms and lubricant and can serve as a box for carrying PrEP pills. In addition to convenience, such a box brings a certain message — PrEP is good, but in the case of a risky contact it is worthwhile using a condom and lubricant.
In the final part of the lecture, Demeter paid attention to bacterial sex infections, such as syphilis, gonorrhoea and chlamydia (STIs). In his practice, more than 70 percent of people starting PrEP had problems with STIs. With the appointment of PrEP Demetre proposed to do an anal and oral cavity swab and was surprised that many men reported that they were doing such a test for the first time in their lives. Therefore, HIV prevention programs are able, with a competent approach, to prevent the spreading of bacterial infections.
Lecture Demeter Daskalaskis turned out great, and in our review, we retold only a part of the information. If you are interested in listening to the lecture in full — subscribe to the PrEParing course on the Coursera platform following the link https://www.coursera.org/learn/prep or ask Demeter directly via email firstname.lastname@example.org.
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