PrEP Service Provision and Outcomes following Covid
Pre-Exposure Prophylaxis Drugs (PrEP) for partners of HIV positive people have been readily available on the NHS since 2018.
However worldwide only 50-60% of people will come back for follow up. This may be because they may not need it anymore as their circumstances have changed, they may be single or in an exclusive relationship. Also, there may be hesitance or resistance for coming forward, from some. Our goal is to normalise PrEP like that of the contraceptive pill, and so destigmatise its use.
Most sexual health services rely on patients contacting the service themselves to obtain further supplies of PrEP. During the Covid pandemic many people didn’t contact their sexual health service and therefore stopped using PrEP due to a decrease in contact with people. However, there was concern when contact returned that people were being put at risk.
Pre-Covid the Cardiff PrEP service was delivered as a face-to-face clinic with booked appointments. Demand was outstripping supply with a waiting list of over 12 months to join the service, and 115 people waiting in March 2020.
In order to adapt to the COVID 19 Pandemic, the Cardiff team developed a new way of working: -
- They cold called patients that had previously taken PrEP but had stopped, to ask whether they needed to start again to maintain good health.
- They set up an access for all drop-in service for PrEP patients every Tuesday evening via the Attend Anywhere Video consulting platform.
So, patients were given the option of being seen via telephone appointments or by video appointments.
They also worked alongside Frisky Wales (PHW) to reduce the increased prescription lengths between consultations. Frisky Wales (PHW) commenced postal kit testing for STI’s, HIV and eGFR & creatinine monitoring.
As services have gone back to near normal, the patient still has the option for face-to-face appointment but also now has the choice of telephone or video consultations as well.
The project aimed to evaluate whether the post COVID PrEP delivery model was meeting the BASHH BHIVA guideline standards 2018-PrEP-Guidelines.pdf (bhiva.org) comparing it to the quality of the pre COVID delivery model. The results would be used to continue to improve and evolve the service.
The expectations were that this new way of working would deliver the following benefits:
- Reducing waiting time and potentially harmful delays
- Avoiding harm to patients
- Avoiding waste
- Providing services to those who need them
- Providing fair and impartial service
- Respecting and responsive to patient preferences
- Full Project Report
- Lessons learnt
There may be a public health benefit in ensuring PrEP users are actively followed up after PrEP provision to ensure those at highest need continue to access this biomedical HIV prevention strategy. Cardiff PrEP services have a cultural continuous improvement so constantly looking and seeing how they can improve and evolve the service to meet the needs of the population and so are working alongside the Welsh Gender Service, CAVIS (Cardiff and the Vale Inclusion Service) and Wales HIV Action plan to help with the accessibility of PrEP.
- Having a digital service makes it easier for patients to engage providing more accessibility.
- A regular virtual drop-in session has helped empower patients in taking control over their health.
- Shortening the time for people to receive PrEP. Before Covid it could take up to a year. Now it is 2 weeks via the digital service. This timeframe reduction is critical in helping to reduce the chances of getting HIV.
- Due to the digital service being patient initiated, the DNAs (did not attend) are zero. Therefore, clinician’s time is not being wasted whereas before during face-to-face bookings patients would not always attend.
- Pre Covid 250 people were being seen a year. Now 800 people are being seen a year. Not only has the backlog been cleared but capacity has been dramatically increased by using the digital service.
- Nine months after implementing the new ways of working the waiting list was eliminated.
- Patients were able to directly join the service from online testing done elsewhere, moving to a proactive service as opposed to waiting for contact or referrals.
- Patients were able to request services 24/7 through Microsoft Forms, with some requests coming at 3am, providing a much more convenient and responsive service.
- Positive feedback from patient
- Much quicker time between first contact and picking up medication (as little as 5 days)
- Patients passed text message info between sexual partners, proving their perceived value of the service, and reaching a wider high-risk audience
- Baseline testing has reduced the time patients spend in clinic
- Reduced need for patients to travel to clinic with telephone and video consultations available
- Anecdotal evidence of increased confidence in prescribing PrEP, enabling patients to access PrEP where and when it suits them, including those not able to use online services
- Rapid implementation of the project and use of technology enabled several iterations of action, observation, research, and planning allowing for service improvement.
There were no diagnosis of HIV or severe renal disease in the patient population who had used the new service, suggesting that the service remains safe.
The evaluation proved that the service:
- Was safe and effective
- Could proactively recruit patients, increasing outreach
- Reduced waiting times and increased the number of patients seen
- Required administration and set up time but provided clinical efficiencies
- 196 avoided face-to-face appointments in 6 months – 38 required no clinical contact