Difficulties connecting with physicians mean not all people at risk of acquiring HIV have access to PrEP. Putting nurses on the front lines could change that.
Because it’s so important to make sure that pre-exposure prophylaxis (PrEP) is available to people at risk of acquiring HIV, a team of investigators at the University of Ottawa in Ontario, Canada, has proposed that nurses be on the front lines of providing PrEP. Most current guidelines for PrEP are not written for non-prescribing clinicians such as nurses, even though they may be uniquely positioned to assess patients and recommend PrEP.
The team, led by Patrick O’Byrne, RN-EC, PhD, associate professor of nursing at the University of Ottawa, published a research paper citing several studies demonstrating that a dearth of medical providers—including providers who are aware of PrEP and its specific requirements for dosing and follow-up visits—is 1 reason not enough people have access to the medication. Another reason is that physicians don’t necessarily discuss sexual orientation or sexual history with their patients. These barriers can be surmounted, the investigators posit, by allowing nurses to dispense PrEP. A nurse practitioner can prepare prescriptions for PrEP that can then be handed out by nurses as necessary.
The investigators specifically recommend that registered nurses provide PrEP in the setting of sexually transmitted infection (STI) and HIV testing clinics, an approach they refer to as “Pre-Exposure Prophylaxis-Registered Nurse (PrEP-RN).” “We suggest that medical directives and established pathways to interpret laboratory findings be created to allow RNs to provide PrEP, thereby increasing the number of health care professionals who provide this intervention,” the research team writes.
One big benefit? Having nurses disseminate PrEP may offer cost savings compared with having physicians prescribe it. It makes sense, the investigators say, to have nurses offer PrEP, as they are already offering STI testing in many clinics to people who are at high risk of HIV acquisition; it’s well known that people who acquire an STI are more likely to contract HIV. “PrEP-RN thus uses an existing workforce experienced in sexual health to deliver PrEP in STI clinics, which are settings already visited by persons at high risk for HIV,” the team writes.
The article outlines a detailed proposal of how RN-led PrEP clinics would operate. This includes identifying the target population of those at highest risk of HIV infection, such as men who have sex with men (MSM), transgender people engaging in anal sex without a condom and who have been diagnosed with an STI, HIV-uninfected people living with an HIV-infected partner, and anyone who shares injectable drug paraphernalia with people at risk of HIV. The nurse-led clinics would have PrEP available for anyone who feels they are at risk of acquiring HIV.
Nurses would recruit patients via a targeted approach that would allow them to identify people at risk who come in for STI testing, and then initiate a conversation with them. This method would be supplemented with visual prompts for patients to respond to, such as waiting-room posters about the value of PrEP.
Just as important as finding patients who can benefit from PrEP is the need to follow current guidelines on follow-up testing and monitoring. After a comprehensive baseline visit, including a physical exam, various lab tests, and risk-reduction counseling, nurses can then discuss with patients when and if they should begin PrEP. Depending on the decision made, patients who opt for PrEP return after 1 month, and then every 3 months to review lab results, symptoms, adherence issues, and any other issues of concern.
The Ottawa team completed an earlier project that lends support to the idea that PrEP-RN is feasible. In 2014, the team introduced a nurse-led post-exposure prophylaxis (PEP) program in 2 STI/HIV clinics in Ottawa. Those clinics have taken care of more than 300 patients since opening, providing testing, counseling, medication, and linkage to an HIV specialist. Nine percent of the patients were subsequently diagnosed with HIV, but the investigators say this was not a failure of PEP to prevent infection but rather these were new exposures for which the patients neglected to come to the clinic to obtain PEP.
The investigators are optimistic that using nurses to ensure that PrEP is available to those who need it most will prove an easy, safe, and cost-effective way to combat the spread of HIV. “We also feel that by situating PrEP within STI clinics, patients may access combination prevention strategies, which could yield beneficial HIV prevention outcomes and decrease the likelihood of onward STI transmission,” they said in the conclusion of their report. “We have detailed the protocols we developed so that others can modify and transfer these procedures into clinical settings to make PrEP better available and, ultimately, decrease ongoing HIV transmission.”