The role of nurses in eligibility assessment and counseling

As a public health nurse with a focus on sexual health, I work primarily with a population of cis-gender Black, Afro-Caribbean, and Latino men who have sex with men (MSM). They range in age from 19 to 50 and report having multiple sexual partners. During interviews about their interest in pre-exposure prophylaxis (PrEP), they’ve described medication initiation and adherence challenges, including risk compensation, substance use, time constraints, and forgetting to take the medication.

Nurses have a vital role to play in improving PrEP adherence, including counseling and initiation. To best serve their patients, nurses should understand PrEP eligibility criteria and common barriers to its adherence.

PrEP eligibility and adherence barriers

Individuals eligible for PrEP are HIV negative but at high risk of contracting the virus, including those who’ve had vaginal or anal sex in the past 6 months with an HIV positive partner, those who consistently have condomless sex, those who’ve been diagnosed with a sexually transmitted infection (STI) in the past 6 months, and those who use I.V. drugs. According to Heredia and Goldklank, cis-gender gay men are at elevated risk because the incidence of HIV infection is highest in MSM. As a result, they require targeted and adequate access to PrEP. However, many experience challenges to initiating the medication regimen and adhering to it.

In a study conducted by Mannheimer and colleagues, common barriers to adherence include younger age, lower education levels, unstable housing, stigma, complicated work schedules, racial disparities, concerns about long-term side effects, cost, and simply forgetting to take the medication. In addition, some individuals may engage in risk compensation, which can occur at a community level where HIV-negative individuals who are taking PrEP engage in more unprotected sex because they assume that their partners are HIV-negative and also are taking PrEP.

According to a study by Grov and colleagues, some MSM use club drugs (including ketamine, MDMA/ecstasy, gamma hydroxybutyrate, cocaine, and methamphetamine), which can reduce inhibitions and hinder rational decision-making. Shuper and colleagues stated that alcohol consumption may impair an individual’s ability to remember their medication regimen, resulting in poor adherence.

One nurse’s experience

In my work as a public health nurse, I frequently interview patients taking PrEP and those who are candidates for the medication. My responsibilities include screening patients for PrEP eligibility. Typically, eligible patients have multiple sexual partners (some HIV positive), engage in frequent unprotected sex, have a history of hepatitis B or hepatitis C, or they have a substance use disorder.

Many PrEP-eligible patients I work with identify as gay or bisexual cis-gender men, with most being of African American, Afro Car­ib­bean, or Latino descent. After initial screening for eligibility, they’re assessed by the medical provider to begin the first stages of PrEP. This typically involves an in-depth eligibility interview and various lab tests (including a comprehensive metabolic panel, a liver panel, and screenings for hepatitis A, B, and C antibodies) to ensure it’s medically safe for the patient to begin treatment. We determine HIV status via rapid HIV blood testing done in-house and 4th-generation HIV blood testing, which we send to an external lab for confirmation.

If lab results have no significant issues and the patient is HIV negative, the patient can begin the PrEP treatment regimen. After 1 month, the patient returns for a follow-up basic metabolic panel to ensure they’re managing the treatment regimen. If successful, they attend follow-up visits every 3 months to assess regimen adherence, report any side effects, and receive medication refills.

The patients I’ve interviewed at follow-up appointments report various barriers to PrEP adherence. For example, those who work as day laborers have complicated or unpredictable schedules, which they attribute to forgetting to take the medication. Others stated that they weren’t having sex as often so they thought taking the medication was unnecessary (risk compensation), although it could have protected them in the event of spontaneous unprotected sex.

Although some patients’ primary language is Spanish, language barriers don’t present an issue in our setting; several staff, including the physician, speak fluent English and Spanish. These staff members can thoroughly explain the regimen and confirm the patient’s understanding. Because we’re a safety-net location that provides care regardless of insurance coverage or immigration status, accessibility doesn’t present an issue.

However, our clinic currently operates only twice a week (Tuesdays and Thursdays, between 1:00 PM and 5:00 PM). Before the COVID-19 pandemic, we offered walk-in services, but in 2021, at the height of the pandemic, we transitioned to an appointment-only clinic. These operating hours coupled with the physician’s limited appointment availability, have resulted in potentially missed opportunities to screen patients who may have been eligible for PrEP. In addition, because we’re one of the few safety-net referral sites for PrEP in our geographic area, patients without insurance coverage may not be able to find care elsewhere.

Nurses’ role in treatment adherence

Adequate follow-up by the patient and the healthcare staff plays a crucial role in PrEP adherence. In one case study, Jacobowitz Marsh and Rothenberger reported on an 18-year-old patient who was lost to follow up during PrEP treatment and eventually acquired HIV. The patient had difficulty swallowing the pills and stopped taking them while still engaging in high-risk behaviors. The community center and the pharmacy didn’t contact the patient for follow-up or to refill his prescription, and the patient didn’t contact the community center to report his concern. Effective communication and follow-up between the patient and the healthcare team could have helped to ensure treatment adherence.

O’Byrne and colleagues proposed that RNs provide PrEP counseling and initiation in sexually transmitted infection (STI) and HIV testing clinics to address limited access. Clinics can implement these PrEP-RN measures by establishing pathways for nurses to interpret laboratory findings, including HIV status, hepatitis A, B, and C antibodies, and comprehensive metabolic panels. A provider would then prescribe PrEP via collaboration with the PrEP-RN. Many patients who visit STI clinics are prime candidates for PrEP, so this protocol could result in cost savings and improved outcomes. In addition, nurses could provide risk-reduction counseling before PrEP initiation to assess patients’ individual needs, such as condom use and substance use.

In my work setting, public health nurses are available daily for nurse-specific visits, while the physicians and nurse practitioners are available twice a week for sexual health clinic visits. We could use nurse visits for PrEP counseling and initiation, which would provide patients with more appointment flexibility. For example, we could plan Monday and Wednesday afternoon appointments for nurse PrEP counseling and initiation visits and Tuesday and Thursday evening appointments for physician and nurse practitioner visits focused on sexual health and PrEP. Friday appointments could be virtual nurse follow-up visits and phone calls.

Collaboration and communication

The PrEP-RN intervention would allow more healthcare professionals to counsel and initiate PrEP in eligible patients in our setting, especially high-risk populations such as MSM, who frequently voice interest in the medication during sexual health appointments. In addition, more appointment availability during the week would make the treatment more accessible to those with busy or difficult schedules.

Effectiveness of this protocol requires that physicians and nurse practitioners provide professional support to public health nurses and oversee lab result interpretation. In addition, nurse administrators must facilitate effective communication between public health nurses and physicians about patient progress to ensure adherence and ultimately lower the incidence of HIV infections in the community.

Taina M. Benjamin is a public health nurse for the Rockland County Department of Health in Pomona, New York, and a graduate of the Hunter-Bellevue School of Nursing’s Nursing Administration and Urban Policy and Leadership Program in New York City, New York.

References

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Grov C, Rendina HJ, John SA, Parsons JT. Determining the roles that club drugs, marijuana, and heavy drinking play in PrEP medication adherence among gay and bisexual men: Implications for treatment and research. AIDS Behav. 2019;23(5):1277-86 doi:10.1007/s10461-018-2309-9

Heredia JLA, Goldklank S. The relevance of pre-exposure prophylaxis in gay men’s lives and their motivations to use it: A qualitative study. BMC Public Health. 2021;21:1829. doi:10.1186/s12889-021-11863-w

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HIV.gov. Pre-exposure prophylaxis. September 28, 2023. hiv.gov/hiv-basics/hiv-prevention/using-hiv-medication-to-reduce-risk/pre-exposure-prophylaxis

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Shuper PA, Joharchi N, Boguch II, et al. Alcohol consumption, substance use, and depression about HIV pre-exposure prophylaxis (PrEP) nonadherence among gay, bisexual, and men-who-have-sex-with-men. BMC Public Health. 2020;20(1):1782. doi:10.1186/s12889-020-09883-z

United Nations Population Fund. Implementing comprehensive HIV and STI programmes with men who have sex with men: Practical guidance for collaborative interventions. 2015. unfpa.org/publications/implementing-comprehensive-hiv-and-sti-programmes-men-who-have-sex-men

Yan X, Jia Z, Zhang, B. Evaluating the risk compensation of HIV/AIDS prevention measures. Lancet Infect Dis. 2022;22(4):447-8. doi:10.1016/S1473-3099(22)00151-7

Key words: PrEP, pre-exposure prophylaxis, AIDS, HIV