Jennifer Hadayia, MPA, senior director of public health at Legacy Community Health in Houston, Texas, remembers when she first saw at-home HIV testing kits on the shelf of her local pharmacy.
"No," she said was her gut reaction, followed quickly by all the what-ifs. "We won't be there as counselors. We won't be there to address their concerns. And what about the worst-case scenario of somebody who gets a result, is not prepared for it, and has intentions of self-harm or harm to others?"
She didn't imagine, back then, that she'd be championing at-home testing and devising ways to get HIV prevention medications to patients in the comfort of their homes. But then, she never imagined a global pandemic, either.
"Those old models of work aren't going to work anymore," Hadayia told Medscape Medical News during the United States Conference on HIV/AIDS 2020 (USCHA 2020). "We're in a moment where we have to consider a revolution in the way we bring HIV prevention and care services to people."
In Houston, that revolution looks like a reorganization in the middle of a pandemic to achieve a 45% increase in the number of HIV tests completed, with no noticeable decline in HIV preexposure prophylaxis (PrEP) use. There's also been a slight uptick in the absolute number of HIV diagnoses, but Hadayia doesn't know whether it is a statistically significant increase.
A 30% Drop and a Need for a New Approach
Before the pandemic, Legacy Community Health, the largest federally qualified health center in Texas, performed about 3500 HIV tests each year. That's about 291 a month — all of them in person, either at their four health clinics in and around Houston's historically gay Montrose neighborhood or at community events. Annually, they served 5400 people living with HIV while also linking 1200 people to HIV PrEP.
In February 2020, 303 people came in for an HIV test.
"Then March happened," Hadayia said. "All the tests that we were bringing into the community stopped immediately. The majority of our HIV testing staff were deployed to our own coronavirus response."
And just like that, many people were no longer willing to walk into a clinic where people may be sick with COVID-19. Test numbers dropped to 213 and remained in that range. But with new practices in place, in June, testing numbers rebounded to 425, and then to 491 in July. The testing numbers were still in the 400s in August, at 451. What's more, the average number of tests increased from 259 in the clinic to 376 through their new system.
Moreover, there was no drop in the number of people on PrEP, which runs counter to reports from other large organizations that new PrEP prescriptions dropped by 72.1% in the immediate aftermath of the COVID-19 outbreak in Boston.
What that told Hadayia was that clinicians shouldn't assume that if people aren't seeking HIV testing in the same way they used to, it doesn't mean they don't need it.
"Stay-at-home orders are not HIV risk-reduction orders," she said. "We're starting to see just the opposite. As people are staying home, as they are perhaps expanding their bubble or seeking self-soothing behaviors — and sexual activity can be one of those — clinicians shouldn't take patients not seeking testing as an indication that those risk factors have reduced or gone away."
Closer to Home, Streamlined, Integrated
Legacy did a lot to get these results, not all of them home-based. They opened stand-alone HIV-testing-and-PrEP sites in Houston, where patients could be tested for HIV, syphilis, hepatitis C, pregnancy and give specimens for gonorrhea and chlamydia screening — similar to London's Dean Street Express. Because these clinics only saw people seeking HIV testing services, they were isolated from clinics where more people were likely to be sick with COVID-19.
Using New York City's status-neutral testing approach, if a person tested positive for HIV, they would immediately be connected to HIV care. If they tested negative, they could jump on a telemedicine visit with a provider who could counsel them about prevention and, if they were interested, get them started on PrEP, with meds available either the same day from a local pharmacy or the next day by courier.
They added universal HIV screening prompts to electronic health records for all adult clinic visits. If a patient's answers indicate PrEP might be a good option for them, they are offered HIV screening and PrEP initiation via telemedicine at the same appointment, so as not to add another medical visit during stay-at-home orders. They moved from four clinics with walk-in HIV testing to nine and spread out from their usual locations in Montrose and the city's downtown. The idea was that people might be willing to come to a clinic close to home but not travel further into the city.
A "Silver Lining" During COVID-19
And then there were the no-touch options. These included allowing clinicians to prescribe PrEP for 6 months instead of 3 and permitting pharmacists to provide rapid HIV tests when patients came in to pick up their PrEP refills so as to avoid an additional visit.
And then there were the at-home HIV tests.
At-home tests have been controversial for years among clinicians who, like Hadayia, are hesitant to promote testing without pre- and posttest counseling.
But Hadayia said that the pandemic changed things for her. She learned, she said, that "you have to meet people where they are, even if where they are is at home.
"The reality in at-home testing is that people can already do that from the comfort of their homes — they can already order in-home tests online," she said. "The benefit and the protection that you have in those at-home kits coming from us, coming from clinicians, coming from HIV specialists is that you can have that conversation with them first."
Indeed, Legacy Community Health's approach to at-home testing doesn't involve mailing tests to anyone who wants them. Rather, people request tests on Legacy's website and receive a telehealth visit from an HIV counselor. If the counselor agrees that the person is emotionally ready and is supported for an at-home test, clinic staff will deliver it the next day. If they have concerns, staff invite the patient to the stand-alone HIV and PrEP sites for an in-person test.
On that first telehealth appointment, staff schedule a call with the patient for the following week to talk to them about their results. At those appointments, they offer either PrEP or HIV treatment, depending on the results of the test. Hadayia said she doesn't yet know how many people have initiated PrEP or HIV treatment during the pandemic.
They do lose people in this process, especially those who want their test today or who don't want to wait for a call before having a test ordered.
"Still, I think it's the right way to do it," she said.
For Noah Beacom, MEd, prevention specialist at Primary Health Care, in Iowa, who made a presentation at USCHA 2020 on Iowa's approach to home testing and tele-PrEP, it's a welcome spot of good news in a difficult year. He recalled a man who lived an hour and a half outside of Des Moines, Iowa's largest metropolitan area, who told him, "I'm glad somebody gives a damn about this stuff."
Home HIV testing has in the past been found to increase not just the number of HIV tests but also testing by people most vulnerable to HIV. That's what Beacom has found, too.
"This is extremely fascinating and exciting," he said. "One of the silver linings of COVID, if we can speak about it that way, is that we did reach folks in our small towns and rural areas who don't have access to centers of healthcare that are LGBTQ aware, or aware of PrEP."
United States Conference on HIV/AIDS (USCHA) 2020: Workshop session 1: Expansion/Integration: HIV Testing & PrEP During a Pandemic, presented October 19, 2020.
Heather Boerner is a science and medical reporter based in Pittsburgh, Pennsylvania.
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Cite this: HIV Testing Meets COVID-19, and the News Isn't All Bad - Medscape - Oct 22, 2020.