Sharma Malika, Chris Allison, Chan Arlene, Knox David C, Wilton James, McEwen Owen, Mishra Sharmistha, Grace Daniel, Rogers Tim, Bayoumi Ahmed M, Maxwell John, Shahin Rita, Bogoch Isaac, Gilbert Mark, Tan Darrell H S
Division of Infectious Diseases, St. Michael's Hospital, Toronto, Canada.
Department of Medicine, University of Toronto, Toronto, Canada.
BMC Health Serv Res. 2018 Jul 3;18(1):513. doi: 10.1186/s12913-018-3324-2.
Gay, bisexual and other men who have sex with men (gbMSM) in Canada continue to experience high rates of incident HIV. Pre-exposure prophylaxis (PrEP, the regular use of anti-HIV medication) reduces HIV acquisition and could reduce incidence. However, there are too few physicians with expertise in HIV care to meet the projected demand for PrEP. To meet demand and achieve greater public health impact, PrEP delivery could be 'decentralized' by incorporating it into front-line prevention services provided by family physicians (FPs) and sexual health clinic nurses.
This PrEP decentralization project will use two strategies. The first is an innovative knowledge dissemination approach called 'Patient-Initiated CME' (PICME), which aims to empower individuals to connect their family doctors with online, evidence-based, continuing medical education (CME) on PrEP. After learning about the project through community agencies or social/sexual networking applications, gbMSM interested in PrEP will use a uniquely coded card to access an online information module that includes coaching on how to discuss their HIV risk with their FP. They can provide their physician a link to the accredited CME module using the same card. The second strategy involves a pilot implementation program, in which gbMSM who do not have a FP may bring the card to designated sexual health clinics where trained nurses can deliver PrEP under a medical directive. These approaches will be evaluated through quantitative and qualitative methods, including: questionnaires administered to patients and physicians at baseline and at six months; focus groups with patients, FPs, and sexual health clinic staff; and review of sexual health clinic charts. The primary objective is to quantify the uptake of PrEP achieved using each decentralization strategy. Secondary objectives include a) characterizing barriers and facilitators to PrEP uptake for each strategy, b) assessing fidelity to core components of PrEP delivery within each strategy, c) measuring patient-reported outcomes including satisfaction with clinician-patient relationships, and d) conducting a preliminary costing analysis.
This study will assess the feasibility of a novel strategy for disseminating knowledge about evidence-based clinical interventions, and inform future strategies for scale-up of an underutilized HIV prevention tool.
加拿大的男同性恋者、双性恋者及其他与男性发生性关系的男性（gbMSM）中，HIV新发感染率持续居高不下。暴露前预防（PrEP，即定期服用抗HIV药物）可降低HIV感染风险，并可能降低发病率。然而，具备HIV护理专业知识的医生数量过少，无法满足对PrEP的预计需求。为满足需求并实现更大的公共卫生影响，可通过将PrEP纳入家庭医生（FPs）和性健康诊所护士提供的一线预防服务中，实现PrEP服务的“去中心化”。
该PrEP去中心化项目将采用两种策略。第一种是一种名为“患者发起的继续医学教育”（PICME）的创新知识传播方法，旨在使个人有能力让其家庭医生获取关于PrEP的在线、循证继续医学教育（CME）资源。在通过社区机构或社交/性网络应用了解该项目后，对PrEP感兴趣的gbMSM将使用一张唯一编码的卡片访问一个在线信息模块，其中包括关于如何与家庭医生讨论其HIV风险的指导。他们可以使用同一张卡片向医生提供该认证CME模块的链接。第二种策略涉及一个试点实施方案，即没有家庭医生的gbMSM可将卡片带到指定的性健康诊所，在那里经过培训的护士可根据医疗指令提供PrEP。这些方法将通过定量和定性方法进行评估，包括：在基线和六个月时向患者和医生发放问卷；与患者、家庭医生和性健康诊所工作人员进行焦点小组讨论；以及审查性健康诊所的病历。主要目标是量化每种去中心化策略实现的PrEP使用情况。次要目标包括：a）确定每种策略中PrEP使用的障碍和促进因素；b）评估每种策略中PrEP服务核心组成部分的依从性；c）测量患者报告的结果，包括对医患关系的满意度；d）进行初步成本分析。
本研究将评估一种传播循证临床干预知识的新策略的可行性，并为扩大一种未得到充分利用的HIV预防工具的未来策略提供信息。
