Grassroots HIV Prevention Efforts Target Those at High Risk

Nancy A. Melville

November 13, 2017

DALLAS — In populations at high risk for HIV, trained community-based peer navigators can effectively raise awareness about pre-exposure prophylaxis (PrEP), results from a new study suggest.

"We found that community-wide peer navigators are effective in increasing PrEP uptake, but you have to lay the groundwork with training and resources and have realistic expectations about the outcomes," said Paul Sacamano, MPH, ANP-BC, ACRN, from the REACH Initiative at the Johns Hopkins University School of Nursing in Baltimore.

PrEP is highly effective in reducing the sexual transmission of HIV by more than 90%, and transmission related to injection drugs by more than 70%, but global use has been reported to be as low as 5% of the UNAIDS target of 3 million by 2020 (Curr HIV/AIDS Rep. Published online October 25, 2017).

A big part of the problem is awareness, Sacamano said here at the Association of Nurses in AIDS Care 2017.

In a recent study of Baltimore men who have sex with men, less than 11% reported having heard of PrEP, and black men were 52% less likely than white men to have heard of PrEP (AIDS Behav. 2017;21:1268-1277).

This lack of awareness is of particular concern because in Baltimore — which has a higher incidence of HIV than other major cities, including New York City and San Francisco — 83% of those infected with HIV are non-Hispanic black people, Sacamano reported.

The PrEP community-based outreach program is designed to engage the Baltimore population at high risk for HIV, which is predominantly black, of lower socioeconomic status, and living in areas with a high prevalence and incidence of HIV.

This "makes our program different than outreach in places like Washington, New York City, San Francisco, and other urban centers with different demographics and levels of resources available for HIV prevention," Sacamano told Medscape Medical News.

The campaign is unique in its focus on guiding patients to services wherever they are most appropriate and accessible, not just to Johns Hopkins, he pointed out.

"Many peer-navigator outreach programs for PrEP focus on connecting clients to a particular service provider, clinic, or healthcare system," he explained.

Paid Peer Navigators

In the Baltimore program, the paid peer navigators undergo 12 months of training, which covers the basics of HIV and other sexually transmitted infections (STIs), PrEP, and HIV testing, and emphasizes professional communication, respect for confidentiality, documentation, and the discussion of gender, sexuality, and sex from a positive viewpoint.

"One of the important things the peer navigators do is normalize PrEP," said Sacamano. "They're out in the community and talking to people about HIV. I think just seeing someone who is from your community and talking to you about HIV goes a long way in fighting the stigma."

This is especially important in light of research showing that HIV-negative black men who have sex with men have negative perceptions about taking HIV medication (Int J STD AIDS. 2015;26:1040-1048), and that the fear of being stigmatized lowers the likelihood that they will accept or adhere to PrEP (Health Educ Behav. 2016;43:217-225).

Social media plays a key role in community engagement, and navigators use everything from Facebook and Twitter, to dating apps (such as Jack'd and Grindr), to the program website, to the PrEPme smartphone app.

The navigators also work through community outlets, such as bars, health fairs, and churches. Sponsored events, for example, have included a screening of the movie Moonlight followed by a panel discussion.

The peer navigators guide individuals to PrEP providers, try to reduce the associated stigma, and provide information on a wide range of services, such as insurance, dental care, housing, transportation, food services, and trans-friendly resources.

Community members having conversations about sexual health and risk-reduction strategies helps reduce the stigma around sex and HIV.

"We're not just narrowly focused on PrEP," Sacamano explained. "We're also linking people to other kinds of support they need" because many of them face inequities that are barriers to PrEP.

Sacamano and his colleagues assessed the effectiveness of the outreach efforts in their observational analysis conducted from March 2016 to October 2017.

Of the 4359 contacts made with people in the high-risk population, 612 expressed an interest in follow-up contact and 194 followed through on that.

Of the people who followed through, 58 (30%) were referred for a PrEP consultation, 47 (24%) scheduled an appointment, and 24 (12%) completed intake.

Sacamano said he is not surprised by the low intake rate in Baltimore, "given the barriers related to housing, transportation, and employment needs, as well as medical mistrust and the stigma around HIV and sex."

"These are social determinants and systemic issues that cannot be resolved in a single interaction with a peer navigator," he explained.

These observations are consistent with the literature, he added. A nationwide longitudinal study of 995 HIV-negative sexually active gay and bisexual men in the United States showed that about 47.0% expressed willingness to take PrEP, 24.0% were contemplating PrEP, 12.9% had spoken to a provider about initiating PrEP, and 9.1% were in PrEP maintenance and adhering to the treatment regimen (J Acquir Immune Defic SynDr 2017;74:285-292).

Outreach efforts need to close the gap between awareness and willingness to initiate prevention. "We need to focus on barriers to willingness to initiate PrEP in those at high risk," said Sacamano.

The stigma around PrEP services could be eliminated if they were integrated into primary care, rather than being available only in infectious disease, STI, or HIV clinics, he suggested.

The increased comfort patients feel when they can access PrEP at the primary care level was underscored in a presentation by a pair of nurses from Country Doctor Community Health Centers in Seattle.

"Providing sexual healthcare in a primary care setting reduces the barrier of having to walk into an HIV or STI clinic," said Claire Siegel, RN, PrEP coordinator.

"We're able to integrate many things into our PrEP visit, including STI screening, hypertension management, smoking cessation, and vaccinations, so we can really improve the opportunity to educate and advocate for our patients," she said.

Country Doctor, which operates two primary care clinics and one urgent care clinic, treats patients regardless of their ability to pay, said copresenter Haley Barker, RN, who founded the center's nurse-led PrEP program.

Patients at the clinic have proven to be highly effective peer resources. "Our MSM population really tends to self-refer, and many will come in and bring all of their friends," Barker reported.

Mutual support within the community of men who have sex with men has been key to spreading the word, she told Medscape Medical News. "MSM in our community have strong social networks, and since we do not have the capacity for outreach services, they serve as our best link to those that may be at risk in our community," she explained.

"Community members having conversations about sexual health and risk-reduction strategies helps reduce the stigma around sex and HIV and will hopefully help bring at-risk individuals out of the shadows to get tested and on PrEP, if appropriate," Barker added.

The outreach campaign is part of the Initiative to Maximize Prevention, Access to Care, and Treatment (IMPACT), a program funded by a grant from the Centers for Disease Control and Prevention to the Baltimore City Health Department. Mr Sacamano, Ms Siegel, and Ms Barker have disclosed no relevant financial relationships.

Association of Nurses in AIDS Care (ANAC) 2017. Presented November 3, 2017.

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