In addition to the process evaluation findings above, other notable lessons learned include:
· Most individuals who engaged in PrEP have established relationships with HCH (wound care, MAT, care coordination, HIV outbreak response, STI treatment/screening).
· Few individuals have maintained engagement with HCH for PrEP as their sole focus of care.
· Many patients would benefit from a combination MAT/PrEP community-based mobile program.
· Many individuals are interested in Hepatitis C cure and are utilizing PrEP as a means to establish care and readiness for Hepatitis C cure.
· Many individuals are interested in screening for STI, wound care, and other housing/care coordination needs through the medical outreach team.
· Most consistent PrEP coordination and follow-up is in the same or similar geographic area to the HIV outbreak, and so medication coordination is happening across HIV status and in conjunction with Hepatitis C cure and other medical care to reduce stigma and promote engagement.
The objectives of the pilot program were met, but as noted in section 3, the sustainability of the project will largely depend on the bandwidth and resources of staff. However, significantly more engagement and follow up occurred between June and September 2021 after adding dedicated provider hours. These patients are in more consistent care.
Next steps include continuing the pilot as outlined and following up again at 12 months. In addition, further action is being planned that will add a case management assistant to facilitate housing assessments, provide case management, and connect to medical and chemical health services. Health Care for the Homeless plans to continue to refine its partnership with the Red Door Clinic to provide onsite phlebotomy for orders placed by HCH and explore utilization of the Red Door Clinic team to assist with patient assistance program paperwork for those that do not qualify for insurance. Furthermore, additional activities are planned to make the pilot project sustainable, including:
Increasing provider hours and expanding the care team to include others to coordinate medication administration and phlebotomy.
Consideration of models where PrEP would be available at time of visit (samples/stock medications)
Partnering with the newly forming HCH buprenorphine team to offer medication-assisted treatment (MAT) options and care coordination.
Moving towards a culture of offering PrEP to all patients who use intravenous drugs throughout HCH.
Continuing to improve universal HIV screening for HCH patients through the existing opt-out testing.
Continuing to offer and expand harm reduction interventions including syringe services and coordination with community partners for harm reduction.
Stakeholders are invested in the success of this project, especially due to the ongoing HIV outbreak in our region. Stopping the forward transmission of HIV in the unsheltered homeless population, particularly among people who inject drugs, is key to getting the outbreak under control. PrEP offers a way forward and this innovative pilot project expands access to populations that have not typically had easy access to highly effective biomedical HIV prevention.