Pre-Exposure Prophylaxis (PrEP) using the antiretroviral medication emtricitibine/tenofovir approved in countries around the world is a highly effective means of reducing transmission of HIV through sexual encounters and needle sharing. This Johns Hopkins University course PrEPares you with essential information, concepts and practical advice regarding PrEP from leaders in the field. A first of its kind learning opportunity, both providers and patients learn from the same experts through content that meets the needs of both audiences, while facilitating the opportunity for a shared community space. Lessons for healthcare workers provide background on foundational and cutting-edge research and PrEP guidelines, how to initiate a PrEP program, clinical management and providing culturally sensitive sexual health and primary care to diverse communities. Lessons for PrEP enthusiasts, PrEP users or the PrEP curious provide information regarding who can benefit from PrEP, how to access services, what to expect and how to stick with your PrEP program long-term. The Association of Nurses in AIDS Care is providing 9.1 contact hours, 1.2 of which can be use towards pharmacology contact hours for this course. The Association of Nurses in AIDS Care is an approved provider of continue nursing education by the American Nurses Credentialing Center's Commission on Accreditation OBJECTIVES: At the conclusion of the session, the participant will be able to: 1. Describe the differences between foundational PrEP studies and demonstration projects 2. Describe the basic pharmacodynamics of tenofovir/emtricitibine including mechanism of infection prevention and time to protective concentration in mucosal tissues 3. List recommendations from PrEP for Prevention of HIV Infection in the United States clinical practice guidelines, USPHS and CDC, including initial and ongoing screening and testing 4. Describe the need for PrEP as an HIV prevention tool for priority in often stigmatized populations 5. Indicate the components for integrating PrEP services into clinical practice 6. Outline guidelines for screening and treatment of sexually transmitted infections 7. Describe how to take a thorough sexual history and to engage with clients around sex in an affirming and non-judgmental manner 8. List the baseline and follow-up laboratory monitoring required 9. Explain key aspects of patient education for HIV prevention and sexual health 10. Describe protocols for ongoing PrEP services and when to discontinue FACULTY/ CREDENTIALS: Jason E. Farley, PhD, MPH, ANP-BC, FAAN, Associate Professor Johns Hopkins University School of Nursing Chris Beyrer, MD, MPH, Professor Johns Hopkins University Bloomberg School of Public Health Yusuf Ariyibi, BA, Disease Intervention Specialist Baltimore City Health Department Joyce Jones, MD, MS, Clinical Associate Johns Hopkins University School of Medicine Neha Sheth Pandit, PharmD, AAHIVP, BCPS, Associate Professor University of Maryland School of Pharmacy Pierre-Cedric Crouch, PhD, ANP-BC, ACRN, Director of Nursing San Francisco AIDS Foundation Renata Arrington Sanders, MD, Assistant Professor Johns Hopkins University School of Medicine Jenell Coleman, MD, MPH, Associate Professor Johns Hopkins University School of Medicine Michele Decker, ScD, MPH, Associate Professor Johns Hopkins University Bloomberg School of Public Health Deborah Dunn, PA-C, MBA, Physician Assistant Chase Brexton Health Care Jordan White, MS, Desmond Tutu Fellow of Public Health and Human Rights Johns Hopkins University Bloomberg School of Public Health Gregory Lucas, MD, PhD, Professor Johns Hopkins University School of Medicine Demetre Daskalakis, MD, MPH, Acting Deputy Commissioner, Division of Disease Control, NYC Dept. of Health and Mental Hygiene David Dowdy, MD, PhD, Associate Professor Johns Hopkins University Bloomberg School of Public Health Jessica LaRicci, PrEP Coordinator Johns Hopkins University School of Nursing Susan Tuddenham, MD, MPH, Assistant Professor Johns Hopkins University School of Medicine Joseph Cofrancesco, MD, MPH, FACP, Associate Professor of Medicine Johns Hopkins University School of Medicine Jill Crank, CRNP, MSN/MPH, Nurse Practitioner Evergreen Healthcare Paul Sacamano, MPH, ANP-BC, ACRN, PrEP Project Lead Johns Hopkins University School of Nursing Shima Ge, BS, PrEP Peer Navigator Johns Hopkins University School of Nursing ORIGINATION DATE: October 2, 2017 RENEWAL DATE: EXPIRATION DATE: October 2. 2019 URL: https://www.coursera.org/learn/prep/ HARDWARE/SOFTWARE: Computer Hardware; Internet connection; Browser MATERIALS: None TARGET AUDIENCE: physicians, physician assistants, nurse practitioners, registered nurses, pharmacists, health education specialists, public health workers, social workers, case managers PREREQUISITES: None FORMAT: These seminars are enduring video presentations with online discussion forum and resources. CONTACT INFORMATION: Office of The REACH Initiative, Johns Hopkins University School of Nursing (888) 788-7737 ACCREDITATION STATEMENTS: CME activities with Joint Providers: This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint providership of the Centers for Disease Control and Prevention and Johns Hopkins University School of Nursing. The Centers for Disease Control and Prevention is accredited by the (ACCME®) to provide medical education for physicians. Physicians should claim only the credit commensurate with the extent of their participation in the activity. The Centers for Disease Control and Prevention designates this enduring material for a maximum of 10.75 AMA PRA Category 1 Credits™. CEU: The Centers for Disease Control and Prevention is authorized by IACET to offer 1.1 CEU's for this program. CECH: Sponsored by the Centers for Disease Control and Prevention, a designated provider of continuing education contact hours (CECH) in health education by the National Commission for Health Education Credentialing, Inc. This program is designated for Certified Health Education Specialists (CHES) and/or Master Certified Health Education Specialists (MCHES) to receive up to 10.5 total Category I continuing education contact hours. Maximum advanced level continuing education contact hours available are 0. CDC provider number 98614. The Centers for Disease Control and Prevention is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. This program is a designated event for pharmacists to receive 1.05 CEUs in pharmacy education. The Universal Activity Number is 0387-9999-17-232-H01-P. Category: This activity has been designated as Knowledge-Based. Once credit is claimed, an unofficial statement of credit is immediately available on TCEOnline. Official credit will be uploaded within 60 days on the NABP/CPE Monitor. For Certified Public Health Professionals (CPH) The Centers for Disease Control and Prevention is a pre-approved provider of Certified in Public Health (CPH) recertification credits and is authorized to offer 11 CPH recertification credits for this program. CDC is an approved provider of CPH Recertification Credits by the National Board of Public Health Examiners. Effective October 1, 2013, the National Board of Public Health Examiners (NBPHE) accepts continuing education units (CEU) for CPH recertification credits from CDC. Please select CEU as your choice for continuing education when registering for a course on TCEOnline. Learners seeking CPH should use the guidelines provided by the NBPHE for calculating recertification credits. For assistance please contact NBPHE at http://www.NBPHE.org. DISCLOSURE: In compliance with continuing education requirements, all presenters must disclose any financial or other associations with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters as well as any use of unlabeled product(s) or product(s) under investigational use. CDC, our planners, our content experts and their spouses/partners wish to disclose they have no financial interests or other relationships with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters with the exception of Dr. Jason Farley and he wishes to disclose that he received grant from Gilead. Planning committee discussed conflict of interest with Dr. Farley to ensure there is no bias. Content will not include any discussion of the unlabeled use of a product or a product under investigational use with the exception of Dr. Arrington Sander’s discussion of PrEP for adolescents, PrEP is not approved for adolescents < 18 years old; and Dr. Tuddenham’s discussion of STI screening, she will be discussing extra genital screening with NAAT currently recommended by CDC. CDC did not accept commercial support for this continuing education activity. To receive continuing education (CE): Complete the activity Complete the Evaluation at www.cdc.gov/TCEOnline Pass the posttest at 80% at www.cdc.gov/TCEOnline FEES: No fees are charged for CDC’s CE activities.
PrEP Community Outreach in Baltimore
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From the course by Johns Hopkins University
PrEParing: PrEP for Providers and Patients
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From the lesson
Module 4
In this module, we review issues related to accessing PrEP. For providers, we consider how to identify priority populations for PrEP in your service area, discuss the relative costs and outcomes for PrEP as a public health program, key elements of a PrEP business plan and the role of community outreach. For patients, barriers to accessing services are addressed.
Meet the Instructors
Dr. Jason Farley, PhD, MPH, CRNPAssociate Professor
School of Nursing
Hello, I'm Paul Sacamano.
I'm a nurse practitioner at Johns Hopkins School of Nursing and I do HIV care,
and I'm also a doctoral student at the School of Public Health at Johns Hopkins.
And I want to thank you for joining me for the talk today
where we will go over a case study for community outreach for PrEP in Baltimore,
Maryland in the U.S. So through the talk, the objectives are to:
first, describe what is the context for outreach in Baltimore;
talk about our approach to doing outreach in the community, on the streets of the city;
and then, discuss some of the implications around peer navigation in community settings.
So, let's kind of consider what Baltimore is like,
and the way I'd like to do that, first, is by comparing it to two other cities
that are frequently cities of comparison, particularly,
for public health programs in the U.S. - New York and San Francisco.
And just essentially, this brief list of characteristics of population, HIV incidence,
density of the population, percent in poverty, as well as the racial makeup
which is important because it can indicate socioeconomic
and cultural disparities across communities.
So first, New York.
Very large city, we know.
Pretty good incidence of HIV, there are 34 per 100,000 and I do want to note
that these numbers are recent but they may not be the most recent data,
particularly depending on when you're viewing this video.
It has a high density population to about 28,000 per square mile.
About a fifth live in poverty or below the poverty line,
and less than a fifth, identify as African-American or black race.
San Francisco is a much smaller city; has a higher HIV incidence rate;
much less dense, about 18,000 per square mile.
It's a wealthier city, fewer live in poverty
and it has a very small population of people identifying as black.
Lastly, Baltimore, the smallest of the three; HIV incidence however, is the highest;
the density of the city is the lowest by a good margin
and the poverty level is higher than the other two cities.
About a quarter of people in Baltimore actually live at or below the poverty line
and it is a majority African-American community.
Now, the reason that I, again, am describing these characteristics
is that they really do play a role in how we decide to approach community outreach,
and what outcomes we might expect from our community outreach.
A little bit more information about Baltimore, about half of the HIV incidence
is among men who have sex with men, and this is for Baltimore City, not Baltimore County.
There was a recent study by colleagues at the School
of Public Health here at Johns Hopkins that found
that among men who have sex with men in Baltimore City,
only about 11 percent had actually heard of PrEP.
This is a recent publication in 2016, early 2017.
What was associated with a lower likelihood of actually hearing about PrEP?
Well, black race and perceptions of discrimination around HIV.
If somebody had experienced that kind of discrimination or seen it experienced by others,
or was of black race, they were about half as likely
as others to have even heard about PrEP.
In general, among black men who have sex with men, there are a number of factors
that play a role in their ability to connect with care, effective care.
One is that there are unfavorable perceptions
of taking HIV medication when you're HIV negative.
If you're not sick, why would you take this medication?
Why would you go to a clinic?
Uncertainty about the long term side effects of PrEP medication;
concern about stigma, disclosure and gossip around PrEP;
more likely to report taking, talking about sex with a provider as a barrier;
and less likely to report a sense of empowerment
or agency around their medical decision making.
So, key points to wrap up this section are that:
it's important to recognize differences in urban character across cities,
including sociocultural and economic differences of the populations
that you are specifically trying to reach in your community;
and that, approaches in one city may not work in another because of those differences.
And when we're making comparisons of our outcomes regarding outreach for PrEP,
we need to take these things into consideration.
So what is Peer-led Outreach?
In Baltimore, we've come up with a campaign
that is run through the city health department.
It's coordinated by the city health department and it's funded by the CDC here in the U.S.
that is called, the Impact Campaign and its primary goals are to: reduce HIV incidence,
and we're specifically focusing on prioritizing MSM of color and transgender populations.
And you know, do this through increasing the capacity
and demand for PrEP in the community.
It is a collaborative of agencies, community based organizations, clinics,
universities and others working with the City Health Department.
The approach to outreach, in this campaign, is first, to raise awareness of PrEP
and in doing this, providing information and education about PrEP
and linking people to services that they may need, in addition to PrEP care.
We know that if people are having difficulties with housing, nutrition, substance use,
mental health, getting into HIV prevention is not going to be a top priority.
We also focus on retention and adherence once folks are engaged in PrEP.
This is all done essentially through peer navigators.
They are the heart of the program.
So what is Peer Navigation?
Well if you think about peers, they have a shared lived experience,
they may live in the same neighborhood,
they may have experienced the same issues as the clients,
and they will typically have a shared identity as well.
Navigation, we're talking about navigation,
not only to the resources that people may need.
Again, not just PrEP but supportive services including housing,
nutrition, mental health, etc.
But also, and primarily through, the healthcare system itself.
There are a lot of barriers as clients move through the healthcare system,
whether they are financial or otherwise transportation scheduling,
and the Peer Navigators help clients get through those barriers
so that they can access care.
Our Peer Navigators in this program, essentially work in two areas.
One is in the community where they're actually out on the streets,
primarily doing outreach.
And the other is clinic-based navigators that are housed at clinics
and primarily focus on navigating clients once they're linked to care.
This presentation and the information I'm going to discuss going forward
is specifically about the community program.
Both navigators, clinic and community-based navigators,
are paid staff and they went through an initial three
day training when the campaign started.
We wanted to be sure that everybody had a baseline of skill sets and knowledge.
Many of the Peer Navigators actually came in with a great deal of experience
and were able to participate in our training.
And that really has helped the community of Peer Navigators see each other as a resource,
as they continue to work together.
Some of the topics that we covered were just basics of HIV, PrEP and PEP,
talking about sex in a very sex-positive way, how to do a client needs assessment
(in our case specifically around barriers to care and interest in PrEP),
HIV testing window period, supporting clients over the long term
and continuing to adhere to PrEP, and attend clinic visits,
documentation which is very important in the evaluation of the project,
maintaining confidentiality, and then support systems
(not only supports for the client whether they are social supports community groups
but also, for the peer navigators).
This can be a stressful position and we felt that it was important to ensure
that our Peer Navigators had access and understood the means of caring for themselves.
Very, very central to the training and the ongoing work
of our Peer Navigators is the resource guide.
This is a guide that is specifically aimed for PrEP Peer Navigation
but it does include a large breadth of topics, specifically PrEP providers,
but also HIV clinic and support services, substance use, pharmacy services, insurance,
religious support, trans-friendly resources, housing, clothing, utilities.
These are the areas that the Peer Navigators
are able to provide support to clients around,
particularly linking them and getting them access to these resources.
When your messaging around any kind of a public health campaign,
it's obviously important to make the messages relevant
to the community you're trying to reach.
We all get bombarded with a lot of information and messaging, messaging on a given day,
and the information that sticks is going to be that which we can relate to.
So, we have a number of materials that we use for our outreach
that are specifically tailored for men who have sex with men,
women, adolescents, sex workers, transgender women, transgender men, and others.
This outreach material was actually developed in consultation with focus groups
of each of these communities.
So how does the community outreach work?
Well, in the center, we'll see that we have Peer Navigators
that are communicating with each other.
The community navigators communicating with clinic-based navigators,
and the community navigators, in particular,
are encountering clients through three areas primarily: one would be through our website,
prepmaryland.org; another would be through our PrEP line, a free 888 number;
and our social media presence, prep4tomorrow on Facebook.
As well as a phone app, we have called PrEPme, which is available on Android and iPhone.
We also have done some advertising through dating apps, some on buses and billboards.
Although, in our campaign, we have found this to be less effective
than where we spend most of our time
which is actually in the community on the streets talking to people.
In the community, we are focusing on local venues, health fairs, colleges, universities,
HIV testing - is a key place for us to be, to connect with people
that just tested negative and talk to them about PrEP.
So all of these means of linking with clients,
filter into the Peer Navigators that are in the community,
and they then will use an app on their desktop to manage these information,
to document the data, where people are in the linkage to PrEP
and to communicate with patients.
For example, through a chat we have where the desktop app
is able to chat with a client on their phone.
Some of the outreach venues that we have visited,
this is listed just to give you an idea of kind of how broad
of a net that we're casting here to get the word out to raise awareness
and connect people to PrEP.
Health fairs have been very productive, not just large city-wide health fairs,
but actually community health fairs at churches,
small church health fairs in certain neighborhoods,
particularly where HIV prevalence is high.
A number of colleges and universities in the area.
Bars, clubs, celebrations like Pride.
Special events like holding a ball or a skate.
HIV testing services as I'd mentioned.
Conferences, we have a number of local health and social service conferences
where we're not only able to connect with potential clients but also,
colleagues that we would like to become informed
so that they can help us get the word out about PrEP and refer folks to us.
Another important collaborator, a colleague in our outreach work have been organizations
like the transgender action group where we have been able to go out
and do joint outreach to that population.
Some of the special events that we've focused on, and on the left,
you can see an example of our Peer Navigators at a health fair;
but on the right, you'll see an example of a special event,
this is one of several that have happened in the campaign.
This was a movie showing that really was about bringing the community together
to discuss a topic of relevance and importance to the community
and not come out with PrEP first, we didn't want to hit people over the head constantly
with messages of HIV prevention.
It can be stigmatizing and disheartening
when a community is constantly getting that message.
So, we had HIV prevention and PrEP has really integrated into an event
that was relevant to HIV prevention, but was of a larger interest to the community
we're trying to reach out to.
There's an example of our website, PrEP Maryland
and this is not just for clients but also for providers.
It contains, among other things, a list of providers,
has linkages to resources for clients and providers,
as well as a means to contact a Peer Navigator.
On the right, is a screenshot from the phone app,
PrEPme, and this is just the entry screen.
Once somebody registers and gets in,
they can either choose to interact with a Peer Navigator, I'd mention through a chat;
or they can just directly, themselves, find out information about PrEP
and where a nearby PrEP provider is, to make a connection on their own.
So, I think to summarize this section, it's important to remember
that we need to get out and meet clients, where they are in the community,
wherever they are congregating, where they're living, where they experience their lives.
Recognize that they may have different preferences for communication.
Social media may be a preference.
Using an app may be a preference.
Talking to somebody face to face may be a preference.
And use tailored messages that actually reflect their needs and interests.
So, the continuum of outreach in Baltimore,
we've looked at it in terms of first, approaching a client.
So we've had some kind of contact with the client
whether it's at an event, over the phone, or through the app.
Once we've engaged that client, do they actually want to follow up?
Do they want more information?
Would they like to get linked to care?
Oftentimes, when you're at a community event, it's a public affair.
There are a lot of people.
And so the conversations are, of course, short.
So, do people actually want us to talk to them more and give them more information?
If they do, and they gave us their contact information,
where we're successful in actually contacting them.
Did they, once upon that follow up contacted,
they actually want a referral to a PrEP provider?
Were we able to get an appointment schedule?
And then lastly, did they actually attend the clinic visit?
Once the hand-off is made to a clinic, the community role
of a Peer Navigator essentially ends,
particularly if there is a clinic-based Peer Navigator,
but not in all cases if the clinic does not have
that kind of support staff to help patients,
it may be that the community navigators continued to work with that client.
So, again, if there is a clinic navigator at that point they will pick up
and focus on retention and adherence.
These are some results over about a nine month period of outreach in Baltimore.
And these are the categories, the steps that you had seen in the previous slide,
broken out by how clients came to us through the web, over the phone line,
or through our outreach activities which again is really
the bulk of where we're connecting with people.
And you can see a rather steep decline from the number of people
that we've touched in some way that we've actually given information,
to those that are actually giving us information for follow up
that want us to follow up with them, that we've been successful contacting,
that we got an appointment for and that actually showed up and completed and take.
So why this steep drop off?
Well, we think there are a number of things happening here.
One is social desirability, when you're talking to somebody face to face at an event,
and they asked you if you'd like to have more information and follow up, folks maybe,
may want to be just friendly and actually say yes
when in reality they may not be that interested.
So we believe there's a large proportion
of that happening which is difficult to screen for.
It may be that they are actually aren't at risk or they are at risk
and they don't think they are.
It may also be that they have much larger issues.
As mentioned previously, things like housing,
nutrition that put HIV prevention at a much lower priority on a day to day basis.
And there may be barriers to actually agreeing to get involved with a PrEP program
even if somebody is at risk.
And finally, we know that there are significant barriers to healthcare,
particularly to disenfranchise communities that are experiencing poverty,
racism in particular.
So, the realities of outreach that we have learned from this program.
First, it may not be an immediate uptake of PrEP from the initial contact that we have.
We make contact, we raise awareness but moving to interest and actual linkage to care,
that willingness may not happen in two months, three months, six months...
it may not even happen in a year.
Secondly, it may not be a linear path.
People may move through these linkage to care steps,
they may require several contacts regarding awareness and reminding
about the opportunity to use PrEP as an HIV prevention tool
before they actually make a decision and move on to using PrEP.
And it also may be that there are other approaches
with peers that might be useful that we haven't employed
that might be something to consider in the future.
In particular, engaging with informal social networks
and opinion leaders in the social networks that can diffuse information
and adoption of behaviors like PrEP in their social networks, sometimes, more effectively
than a professional healthcare worker or even a paid Peer Navigator.
So to wrap up here, efforts to raise awareness, maybe most importantly,
done along with addressing stigma and normalizing PrEP in the community
through our outreach activities.
It is not just passing out flyers and giving people a list
of providers where they can get PrEP.
So, in conclusion, I would like to acknowledge the colleagues
at the City Health Department, the support from the CDC for this program,
and all the other collaborators in the IMPACT program.
And obviously, the clients, the community,
and our Peer Navigators that are again the heart of the program.
Thank you for your interest and attention.
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