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Original article
peer-reviewed

# Community-Based, Rapid HIV Screening and Pre-Exposure Prophylaxis Initiation: Findings From a Pilot Program

### Abstract

#### Objective

Many individuals do not have regular access to medical care and preventative health services, suggesting the need for alternative access to HIV testing and pre-exposure prophylaxis (PrEP). The purpose of this study is to describe a novel, community-based HIV screening, a PrEP initiation program, and report preliminary findings.

#### Methods

One Tent Health, a 501(c)(3) nonprofit organization, launched a pop-up HIV screening and PrEP initiation program in high-risk areas of Washington, DC in 2017. We describe the unique features of the program and report 25 months of screening, risk assessment, and PrEP education data. Odds ratios were calculated to identify disparities in both HIV risk factors and prior HIV testing.

#### Results

Between October 2017 and November 2019, 846 individuals underwent HIV screening. Six individuals (0.709%) screened HIV-positive. Approximately 13% had never been screened for HIV, and another 13% had at least one major risk factor for HIV. Individuals who self-identified as White were more likely to have risk factors (OR 2.19, p = 0.0170) and less likely to have ever been tested (OR 0.50, p = 0.0409). Individuals who self-identified as Black or African American were less likely to have risk factors for HIV (OR 0.57, p = 0.0178). Disparities by sex and gender were also observed.

#### Conclusions

This program appears to be the first of its kind within the United States. We found the program to be cost-effective, well-received by the community, and accessible by high-risk and unreached populations while further revealing the role of race and gender in the HIV epidemic.

### Introduction

Early diagnosis and treatment remain key components of reducing transmission and improving the health of people living with HIV (PLWH) [1]. In the United States (US), ongoing localized epidemics require innovative disease burden reduction strategies. Washington, DC has the highest incidence and prevalence rates of HIV infection as compared to all states in the US [2]. Prevalence estimates indicate approximately 2% - 3% of the DC population are PLWH, potentially double or triple the WHO threshold for epidemic status [2-4]. Further, the incidence of new HIV cases in DC did not decline between 2014 - 2018 [4].

The history of this localized epidemic is complex, though it is clear that HIV rates correlate with factors such as income, racial background, and sexual partners [5-6]. Governmental programs focused on risk reduction have demonstrated uptake; for example, the DC Department of Health reported that in 2016 over five million male and female condoms were distributed, while nearly one million used needles were collected [7]. Yet, gaps in HIV prevention persist; nearly 25% of those who screened HIV-positive remained without linkage to care (LTC) within three months of screening [5]. Further, the lifetime risk of acquiring HIV remains as high as one in 13 in DC compared to about one in 100 for the nation as a whole [8]. Ideally, all residents aged 15 to 65 would receive their recommended HIV screening once and subsequent tests as dictated by lifestyle risk factors [9].

Many individuals at high risk for HIV infection do not have regular access to medical care and preventative health services, thus suggesting a need for expanded testing programs [10]. Community-based screening programs in a wide range of settings have previously been explored as a means to address this problem [11-14]. These programs, including mobile, door-to-door, school-based, and other non-facility-based screening, have led to earlier diagnosis, higher average CD4 count at the time of diagnosis, and a higher intake of patients never screened before [13]. In urban settings in the US, those at high risk for HIV were more likely to seek care in these non-traditional screening options [15]. Community-based programs also reported equivalent LTC parameters as compared to facility-based centers [13]. These findings demonstrate the utility of community-based screening options, particularly in high-risk areas.

#### PrEP education and linkage

Although PrEP is a mainstay of HIV prevention [20], there are significant concerns regarding the need for novel methods of PrEP delivery [21-23], and healthcare providers’ limited knowledge of PrEP may be a contributor to reduced uptake [24]. Accordingly, less than 30% of our clients had ever heard of PrEP, and only 0.88% were taking PrEP. After a brief education, 27.36% of the clients requested a same-day PrEP prescription, though a smaller proportion indicated risk factors suggesting an indication for a prescription. The observed low use of PrEP, despite risk factors, correlates well with the extant literature, and this pop-up model may be well-designed to reduce the gap both in education and prescription. Further data regarding PrEP uptake and long-term adherence from this program are needed.

#### Program feasibility strengths

While community-based screening comes in a variety of formats, brick-and-mortar clinics and mobile units can be limited in efficacy by spatiotemporal requirements, operational costs, and staffing needs. This rapid pop-up model is designed to reduce such barriers as follows:

Spatiotemporal Requirements

Traditional clinics are often subject to limited hours of operation and are not always located in the highest-risk areas of DC. Some clinics only have HIV screening and LTC services at certain hours of the day, while others may have prohibitively long wait times. All such clinics require individuals to know their physical locations and to take the initiative to seek out their services. Individuals unaware of their risk factors or their preventative care needs maybe even less likely to seek care. Regarding mobile vans, these are conceivably difficult to park in public spaces that have the highest foot traffic.

The pop-up tent model allows for screening on weekends and at multiple locations throughout the city where mobile units might not typically have the space for operations. OTH targets areas, such as grocery stores, pharmacies, and laundromats, where visibility reduces the burden on individuals to seek care.

Operational Costs

OTH spent $138,367 on operations over 25 months of screening or approximately$66,416 per year, a significantly lower cost of operation than a typical brick-and-mortar clinic or even a mobile van screening program [16]. The use of a tent, which costs approximately \$500, is a major factor in the cost reduction. Screening kits were provided free of charge by the DC Department of Health and thus do not factor into the operational cost. Expenses such as insurance, licensing, equipment, and others are included in operations costs.

Staffing

Staffing models influence both feasibility and operational costs. The screening kit used by OTH is under CLIA-waived status, and as the operational focus is specifically HIV screening and PrEP education, clinicians are not required on-site. PrEP prescription and other medical care are instead provided by clinical partners during referral or LTC. Screening sessions are thus performed by volunteers who are trained with knowledge and skills to provide rapid HIV screening and PrEP education, risk factor assessment, and LTC. These non-clinical volunteers can also enhance their engagement by serving in leadership and education roles. As community engagement is considered a critical component of improving outcomes for PLWH [25], this unique model contributes to community engagement around HIV and provides an opportunity for young adults to engage in preventative HIV services.

Reducing Stigma

It is difficult to measure how an HIV screening program might directly reduce the stigma surrounding HIV and HIV screening. Fear and misunderstanding about transmission may be a driver of stigma, perhaps a relic of early misconceptions of HIV. For this reason, OTH opted to make education about HIV and PrEP a centerpiece of the program, a decision that may help reduce bias and misconception. The visibility of the program, in open spaces available to the public as opposed to behind closed doors of clinics, may also contribute to normalizing HIV screening and other preventative health measures. A small minority of persons who underwent intake ultimately chose not to receive HIV screening (n = 37, 4.19%). While no data are available regarding their decision to forego screening, a variety of factors, such as wait time or anxiety about results, could act as deterrents.

#### Limitations

Several limitations are worth noting. LTC and lost to follow-up (LTFU) are established challenges of many organizations, with as much as one-third LTFU at 12 months and more than half not retained in care [26]. Many factors likely contribute to LTFU, including limited transportation, time restrictions, insurance needs, anxiety regarding HIV diagnosis, relocation, and dissatisfaction with a provider. While the timely receipt of screening results (an area where the OTH model excels) is associated with LTC [27], there is significant room for improvement in successful LTC. The benchmark for this metric does not appear to be established, and there was a small total number of OTH clients who screened positive. However, replication of this model may benefit from incorporating additional LTC resources, such as patient navigators or case managers. Additionally, while limited on-site staffing and other resources may reduce throughput time and increase client satisfaction, this is coupled with the drawback of limited opportunities to address other medical concerns, provide on-site confirmatory testing, or initiate treatment. Furthermore, while the INSTI® HIV 1/2 Rapid Antibody Kit is reported to be very accurate [28], there is limited data on the final confirmatory testing of OTH clients who screened positive. Finally, while the pop-up tent model has the benefit of markedly reduced operation costs, data are not available for a cost-effectiveness analysis at this time.

### Conclusions

The OTH pop-up model is a feasible and effective way of increasing community-based HIV screening and identifying a higher rate of newly positive HIV cases than traditional testing methods in the District of Columbia. By reducing access barriers, stigma, and costs, the OTH model provides a unique and needed platform for improving community engagement, HIV education, risk reduction strategies, and knowledge and prescription of PrEP. Organizations with a wealth of resources and staff may benefit from the judicious application of those resources to their community-based screening, as these may decrease efficiency and patient satisfaction. However, after the conclusion of the pilot program reported here, this model was later adapted to include a COVID-19 screening program, alongside HIV screening, which did require an increased number of staff members. LTC remains a challenge in pop-up HIV screening, but organizations should maintain a clear LTC plan and same-day LTC should be prioritized. Patient navigators and enhanced patient contact should also be considered, as these improve retention in care in a variety of settings, and may also be beneficial when implementing a pop-up model. We find that this healthcare delivery model reaches critical populations with risk factors for HIV and can be easily replicated to provide other health maintenance activities, which may be important during both the COVID-19 pandemic and the ongoing global HIV epidemic.

### References

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Original article
peer-reviewed

### Author Information

###### Ethics Statement and Conflict of Interest Disclosures

Human subjects: Consent was obtained or waived by all participants in this study. Mass General Brigham Institutional Review Board issued approval 2019P003138. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: David Schaffer and Lindsey Sawczuk declare(s) employment from One Tent Health. David Schaffer and Lindsey Sawczuk have previously received salary for their employment by One Tent Health. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

###### Acknowledgements

The authors would like to acknowledge Mackenzie Copley, co-founder of One Tent Health, without whom this program and research could not be possible.

Original article
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