Lowering Barriers to Engage Hard to Find Communities in PrEP Merge Ahead! Steering HIV Prevention into the new landscape February 2016 data through 31 March 2015 Jessica Horwitz FNP-C, AAHIVS Alfonso LaCorte CCMA, CPT

CRUSH/PREP Cohort Overview Context/Background CRUSH overview Addressing Barriers to accessing PrEP Lessons Learned CRUSH/PREP Cohort Overview

Why a sexual health clinic for young MSM? What would the model be? New cases are increasing among MSM, and in particular African Americans young MSM/MSM of color MSM between 18-29 made up 81% of new cases between 2010-2012 in AC ACA/Covered CA meant push to get younger people enrolled in health service NO municipal/public supported STI clinic in Alameda County New HIV cases appear to be increasing among MSM, and decreasing among heterosexuals": -Heterosexuals make of 18.9% of all PLWH at the end of 2012, and 9.8% of new HIV infections between 2010-2012 -MSM made up 64.9% of all PLWH at the end of 2012; they made up 73.2% of all new HIV cases between 2010-2012 "The epidemic has disproportionate impact on African American and Latino MSM" -AA and Latino MSM 53% of MSM living with HIV in Alameda County (including MSM who inject drugs)-AA are 34.9%; Latinos 18% -Of ALL new cases 2010-2012: African American MSM 36.9% and Latino 22.9% "The youth epidemic is being driven in large part by increase in new infections among MSM of color" --MSM between the ages of 18-29 made up 81.4% of ALL new cases between 2010-2012 --Among young PLWH (18-29), persons of color make up 86.8% of all PLWH at the end of 2012 -- 82.8% of all new diagnosed cases are between 18-29 year olds between 2010-2012 Why a sexual health clinic for young MSM? What would the model be?

EBAC and Downtown Youth Center East Bay AIDS Center…..Downtown Youth Clinic (1997) HIV primary care center, psychosocial, and peer treatment based services for HIV + youth (13-29 yrs) “Clinic without walls”: Linkage and retention, TAKEN TO clients- at their homes, at other agency sites; clinic cellphones and communicate with clients via text messaging Enhanced access: Flexible drop in provider availability; non punitive if missed appointments; Approx. 220 HIV Positive youth <29 Over 80 % MSM 70% virally suppressed EBAC and Downtown Youth Center

Establishing a Model Sexual Health Clinic: CRUSH PROJECT California HIV/AIDS Research Project: Epidemiological Interventions Initiative (EII) Novel approaches to addressing the HIV prevention care and treatment continuum (PrEP-TLC +) Funded April 2013, 4 years, 3 sites in CA: multi- million state wide investment Goal of CRUSH: To integrate routine sexual health services for Y/MSM within the setting of an existing HIV primary care clinic (including the provision of PrEP) Establishing a Model Sexual Health Clinic: CRUSH PROJECT

HIV Negative Cohort First participant enrolled on 2-10-2014 FINAL DATA First participant enrolled on 2-10-2014 Last participant enrolled on 11-6-2015 281 total participants 177 currently enrolled 66 have completed follow up 21 are past 12 months and lost to follow-up 17 discontinued before 12 months To be completed HIV Negative Cohort

Who is choosing PrEP? Ethnicity Referral Source FINAL DATA Ethnicity Referral Source Maybe add referral source Who is choosing PrEP? 252 individuals, predominantly male. Age: 24.7 ± 2.9

Barriers to Accessing PrEP NO municipal/public supported STI clinic in Alameda County Lack of insurance and primary care services Transportation Primary care providers lack of experience and comfort prescribing PrEP What is sexual health?! Prevention vs Treatment Shame and stigma Barriers to Accessing PrEP

Reducing Barriers to PrEP Access Open door clinic without strict appointment times Retention Coordinator Patient Navigation: warm handoffs Benefits Counselor Patient Assistance Program navigation Sex positive clinical environment – from start to finish Reducing Barriers to PrEP Access

PrEP Retention and Adherence Support PrEP Navigation & Retention Coordinator: First point of contact, patient navigator, back up test counselor Peer support Weekly review of missed visits, medication pick up’s Text reminders for up coming visits, questions Visit navigation and warm hand-offs PrEP Retention and Adherence Support

Accessing PrEP Benefits Counselor Insurance Explanation of current benefits and out-of-pocket costs Patient Assistance Program navigation Co-Pay Card PEP Access Patient Assistance for those without health insurance Accessing PrEP

Lessons Learned: integrating Sexual Health/PrEP initiatives Clinical: 10% at baseline seeking PrEP actually need PEP: Solidify warm hand-off for primary care services for HIV negatives Administrative: Cross-training staff: HIV testing, intake, consent, lab processing, referrals Administrative challenges working within a hospital system Developing & documenting clinical flow is crucial & ever changing Strengthening intra-agency collaboration ultimately helps with clinic flow Developing assessment tools for clinical and program staff to address the PrEP to PEP interplay Increased STI treatment 3 fold: Nurses were like “WHAT????”

Lessons Learned Community: Establishing a robust Community Advisory Board Discussion with partners “What does sexual health mean? What are the outreach messages for Y/MSM?” Your patients are your strongest referral site- good and bad Lessons Learned

Acknowledgements: Our Funder: CHRP The CRUSH and DYC Team at EBAC Our UCSF/CAPS Evaluation Team Our CAB and community partners