The Florida Department of Health in Miami-Dade County's (DOH-MDC) role is to promote and protect the health and safety of all residents. The agency, located in an urban area, delivers public health services to over 2.7 million county residents with 65.0% identifying as Hispanic/Latin and 17.1% as Black/African American. The 2010 US Census identified that 51.1% were foreign-born. The agency has three leading roles: health protection from environmental hazards, promote health protecting behaviors, prevent epidemics and disease transmission, and providing health treatment to individuals with a lack of access to health care services. The website for DOH-MDC is FloridaHealth.gov.
There are over 100,000 HIV-infected Floridians and over 4,500 new infections per year. Florida takes a national lead for new infections with the epicenter of cases located in Miami-Dade County. In 2012, the US Food and Drug Administration approved pre-exposure prophylaxis (PrEP), a daily pill that can prevent the acquisition of Human Immunodeficiency Virus (HIV). The Centers for Disease Control and Prevention reported that PrEP could lower HIV risk by more than 90% for individuals with sexual exposure and more than 70% for injection drug use. Impact models have estimated that 50% population coverage and modest adherence to PrEP by high-risk men who have sex men (MSM), the largest affected community, could reduce new infections by 29% over 20 years. Several municipalities have reported significant reductions in HIV incidence attributable, at least in part, to scale-up of PrEP services.
An analysis of the 2016 HIV testing data for Miami-Dade County, Florida found about 30,000 negative individuals with identified risk factors for HIV acquisition, but at the time an estimated 700 individuals receiving PrEP care. The 35.4% of PrEP candidates not engaged in PrEP care marked a missed opportunity to connect individuals to services during an HIV testing session.
The way a client receives a referral has an impact on the perception of the encounter and may influence his or her decision to engage with services. Referrals can be active, when personnel initiate services on behalf of the client, or passive when a client is provided written resource material or verbally informed where to follow up for services. A 2011 study of HIV counseling, linkage, and testing found that active referrals had a positive influence on the perception of the testing encounter and those who received passive referrals found the contact to be of little or no help. Providing materials, without guidance, can leave the client still unsure how to proceed. Active referrals are more successful and support the provision of an optimal level of service.
In 2018, DOH-MDC implemented PrEPLink, an active referral system, to connect individuals encountered in an HIV testing or outreach setting to a PrEP provider. PrEPLink's goal is to link HIV-negative persons to PrEP care in Miami-Dade County. To accomplish PrEPLink's goal DOH-MDC identified the following objectives: 1. establish a referral network with HIV prevention providers, 2. increase community outreach activities to connect HIV-negative persons at risk to services, and 3. track the linkage to care rate of individuals screened and connected to services.
PrEPLink allows staff to initiate services on behalf of the client by using a referral form and electronically submitting the referral to an identified PrEP agency, within PrEPLink's network of providers, to initiate contact. The receiving agency has two business days to contact the client and schedule an initial appointment. PrEPLink is capable of rapid exchange of data between agencies for initiation, coordination of a referral, and monitoring PrEP referrals among networks of community partners. PrEPLink has achieved a 53% linkage to care rate. The PrEP continuum of care capture's how many individuals were screened, linked, attended the first appointment, and returned for follow-up care. This cascade allows for DOH-MDC to address gaps between the bars and identify health disparities, while working towards impacting the HIV epidemic. This program is a strategy to address HIV/STDs, increases access to care, and demonstrate quality improvement.
The U.S. Public Health Services Task Force provides guidance that PrEP is offered to persons at risk for HIV infection include men who have sex with men, persons at risk via heterosexual contact, and persons who inject drugs. Over 1.2 million Americans, including nearly half a million MSM, meet the criteria, outnumbering the estimated total of only 79,684 PrEP prescriptions written from 2012 to 2015 Moreover, only 7.6% of PrEP prescriptions were for youth younger than 25 years, despite this group accounting for 22% of new US HIV infections. Similarly, 10% of prescriptions were for blacks, a population which represents nearly 50% of new infections.
A sample of Miami-Dade County residents asked about PrEP awareness measured from 2011 to 2014 reflected an increase from 19.4%–41.2%. From the survey, 60.6% of participants reported being very likely to initiate PrEP if it was available for free or covered by insurance, but only 1.4% used PrEP in the last 12 months. There have been documented numerous structural, social, and logistical barriers impacting PrEP access in Miami. For individuals motivated to access PrEP, making an appointment with a PrEP prescriber can be the most significant hurdle.
To remediate the gap of awareness and PrEP services DOH-MDC opened a PrEP clinic in 2016 to provide access to care for all individuals, regardless of insurance status, and provide patient navigation services. Since the clinic's opening, the number of PrEP prescriptions has doubled (663 to 1,867). The PrEP-to-Need ratio, which indicates the number of PrEP users compared to new HIV diagnoses, also remains high. In 2016, there were 0.5 PrEP users for every one new HIV diagnosis, and as of 2018, there are 1.6 PrEP users for every new HIV diagnosis. The goal of this ratio is to have a higher amount of PrEP users, then new HIV cases indicating a level of population coverage and protection.
In a local Miami clinical trial, researchers identified that black and Latino MSM, younger individuals, and those with a lower educational level were less likely to self-refer. PrEP data at the county-level cannot be broken down by demographics; however, an analysis of the 2016 HIV testing data shows 80.4% of Miami-Dade County's HIV tests were with African American/Black and Hispanic/Latinx, with 9.0% of individuals identifying as MSM, and 20.7% with youth ages 18-24. There were 35.4% of candidates not engaged in PrEP care marked a missed opportunity to connect individuals to services during an HIV testing session. Understanding that these groups are less likely to self-refer, PrEPLink's referral system provides these individuals an opportunity to connect through care with staff assistance.
Individuals testing HIV negative or encountered in outreach who report interest in PrEP or any of the following risk factors for HIV infection receive informational materials, counseling, and offered a referral for PrEP services. The following risk factors identified include: 1) MSM or transgender individual reporting sex with more than one partner; 2) heterosexual men and women reporting >1 partner and history of sexually transmitted infection; 3) all individuals reporting the exchange of sex for drugs or money; 4) all individuals reporting sex with an HIV positive individual; 5) all individuals reporting injection drug use; 6) all individuals reporting sex with someone known to use injection drugs; 7) all women reporting sex with a man who also has sex with men. These selected categories are used in the current standardized DOH HIV testing form completed for everyone initiating an HIV test and is therefore available across all DOH-supported testing sites in Miami-Dade County.
The above risk categories from 2016 testing forms was used to estimate the number of PrEP-eligible clients at each PrEPLink site (n=10) to determine the target population size. The total expected number of tests for PrEP-indicated HIV-negative individuals is therefore 5,235 a year. Based on an estimated 10% interest in a PrEP referral among those determined to be at risk (a very conservative estimate), the target is 524 referrals a year between these agencies. The quarterly goal is 131 referrals, PrEPLink has been in operation for one quarter and has generated 96 referrals. The reach to date with this project has been 73%. This program addresses linkage to care for PrEP in Miami-Dade County for the first time.
There are over 20 identified PrEP providers in Miami-Dade County, but before PrEPLink's existence, an individual encountered in HIV testing, outreach, or clinical setting must be self-sufficient in starting PrEP services. PrEPLink is an innovative approach to linkage for HIV-negative individuals. When an individual is interested in starting PrEP, the staff member completes a referral form and the client selects an agency from the PrEPLink Network. The staff member submits the referral electronically to the champion staff member of that agency, who has two business days to contact the individual and schedule an appointment. The case is closed after three phone call attempts to schedule an appointment.
The program is modeled after the linkage to care process for people living with HIV. In these encounters, when an individual is identified as positive, medical and outreach teams actively work with the client to provide treatment and care by scheduling appointments immediately and providing outreach workers to address social service needs within 72 hours. The same service was not being provided to individuals wanting to start PrEP. The implications of PrEP to impact the HIV epidemic was imperative that more individuals, especially in a minority jurisdiction be offered the opportunity to engage in care.
PrEPLink's goal is to link HIV-negative persons to PrEP care in Miami-Dade County. To accomplish PrEPLink's goal DOH-MDC identified the following objectives: 1. establish a referral network with HIV prevention providers, 2. increase community outreach activities to connect HIV-negative persons at risk to services, and 3. track the linkage to care rate of individuals screened and connected to services. The conceptualization of PrEPLink began late 2017 with an environmental scan to identify if other jurisdictions had established a referral system and collect example protocols and referral forms. DOH-MDC did identify other jurisdictions with internal referral processes but did not encounter an external interagency PrEP referral system.
DOH-MDC took four months to draft a protocol, memorandum of agreements, and a referral form. To promote community collaboration, DOH-MDC utilized its Miami PrEP Workgroup, a community mobilization of over 30 individuals representing medical providers, researchers, and HIV community agencies that have been working since 2015 in advancing access to PrEP in Miami. The group meets bimonthly to discuss navigation strategies, emerging biomedical research, and local collaborations on promoting PrEP. DOH-MDC sought feedback from the members on the referral form, ensuring it was culturally sensitive, and develop a protocol that was agency-friendly. PrEPLink now remains a standing item on the Miami PrEP Workgroup agenda to keep members informed and allow bidirectional communication with DOH-MDC on opportunities for improvement with the process. Placing the standing item on the agenda allows the workgroup members to have buy-in and commitment to PrEPLink's success.
PrEPLink's network is open to any agency, including federally qualified health centers, community-based organizations, and other facilities in Miami-Dade County that have entered into a written agreement to participate in PrEPLink, which allows for data-sharing between DOH-MDC and the agency to collect outcome data. Since the launch, there are ten agencies actively participating and three agencies pending staff training. Each site identifies a champion that trains other staff, processes referrals, and provides reports to DOH-MDC on patient-related outcomes. The startup cost of this project was $287, which was used to purchase 1,000 3-part carbon copy referral forms. DOH-MDC purchases the referral forms and agencies do not have any costs for participating in the program.
To accomplish PrEPLink's goal DOH-MDC identified the following objectives: 1. establish a referral network with HIV prevention providers, 2. increase community outreach activities to connect HIV-negative persons at risk to services, and 3. track the linkage to care rate of individuals screened and connected to services. The objective of establishing a referral network was met in August 2018 when agencies began joining the network and signing memorandum of agreements. Currently, there are ten agencies and plans to expand pending agency agreements and training. A monthly outreach calendar identifies where staff will be providing testing and outreach. The team is equipped with referral forms before events to ensure successful linkage. Linkage sites can include health education presentations, outreach events at bars, substance abuse treatment centers, and mobile units.
The final objective is evaluated using the submitted referral forms, electronic health records, and agency tracking logs. The referral form captures demographic and risk factors that allow further analysis on reaching appropriate communities in need of PrEP services. This implementation approach not only helps to describe but also intervene on the PrEP care cascade in areas of critical disparities in PrEP uptake. The primary endpoint for PrEPLink is the proportion of individuals appropriate for a PrEP consideration (based on risk information) who receive a PrEP appointment.
There have been 96 individuals linked, with 53% (n=51) connected to a PrEP appointment. The research identified that minorities are less likely to self-refer to PrEP services, PrEPLink connected 88.2% (n=45) minorities of color to services, 76.5% are males (n=39), and 60.8% (n=31) had no insurance. The primary risk factor identified was condomless anal receptive sex followed by multiple sex partners with status unknown. The reason a client was not linked to an appointment was unsuccessful contact after three phone call attempts. After a completed PrEPLink referral, staff explains to the individual to expect a phone call for the next steps. DOH-MDC does not leave a voicemail due to client privacy and protection of health information. Process measures include tracking he business days from identifying a client to making an appointment is 3.87 business days and from successful contact to first PrEP appointment at 8.01 business days. At the end of each month, all agencies receive a report of referrals and communicate program impact and outcomes.
When PrEPLink launched, it was taking 9.62 business days for the first appointment because of the availability of time slots. The clinic schedule was modified to allow for more appointments. There were also individuals encountered in outreach, such as homeless individuals or substance abuse residents, who did not have direct phone numbers. The process was modified to let agencies use a designated third-party individual, such as a case manager or family member, to be contacted and help coordinate appointments.
There are opportunities for improving linkage to care for women and trans-identified individuals. Only 17.7% of referrals have come from this population. Rate of PrEP uptake have steadily increased in the United States, but women remain behind. There has been poor dissemination of PrEP information targeting women. While most attention to PrEP in the US has been focused on gay and other men who have sex with men—who do still carry the greatest burden of HIV infection in the country—women at elevated risk of HIV also are an important population to include. Tracking demographics identified this disparity and the need to increase outreach activities with women and the trans community. With enough data collected, the quarterly goal of referrals will be broken down by demographics to ensure health equity when reaching these groups.
The Miami PrEP Workgroup, PrEPLink agencies, and DOH-MDC are committed to sustaining the practice. Partner collaboration with DOH-MDC has been mutually beneficial with the data sharing of agreements. Starting 2019, DOH-MDC will begin hosting quarterly conference calls with all PrEPLink agencies to identify how to improve interagency collaborations. It has been identified that more discussions are needed to identify what each agency needs to process a referral, such as creating a list of accepted health insurance plans. For community input, PrEPLink remains a standing item on the Miami PrEP Workgroup agenda. This group will continue to provide input on the process and development of material. PrEPLink results have been presented to DOH's Central Office, and there are discussions to expand the program statewide, which will further administrative sustainability and support. A cost-benefit analysis was not conducted. Use of PrEP for HIV prevention has been established that it can prevent a substantial number of HIV infections. Although the intervention is expensive, it outweighs the cost of lifetime treatment for HIV.