A Demedicalized Model to Provide PrEP in a Sexual Health Clinic

Meena S. Ramchandani, MD, MPH; Anna Berzkalns, MPH; Chase A. Cannon, MD, MPH; Julia C. Dombrowski, MD, MPH; Negusse Ocbamichael, PA-C; Christine M. Khosropour, PhD, MPH; Lindley A. Barbee, MD, MPH; Matthew R. Golden, MD, MPH


J Acquir Immune Defic Syndr. 2022;90(5):530-537. 

In This Article

Abstract and Introduction


Background: Sexual health clinics (SHCs) serve large numbers of patients who might benefit from preexposure prophylaxis (PrEP). Integrating longitudinal PrEP care into SHCs can overburden clinics. We implemented an SHC PrEP program that task shifted most PrEP operations to nonmedical staff, disease intervention specialists (DIS).

Methods: We conducted a retrospective cohort analysis of PrEP patients in an SHC in Seattle, WA, from 2014 to 2020 to assess the number of patients served and factors associated with PrEP discontinuation. Clinicians provide same-day PrEP prescriptions, whereas DIS coordinate the program, act as navigators, and provide most follow-up care.

Results: Between 2014 and 2019, 1387 patients attended an initial PrEP visit, 93% of whom were men who have sex with men. The number of patients initiating PrEP per quarter year increased from 20 to 81. The number of PrEP starts doubled when the clinic shifted from PrEP initiation at scheduled visits to initiation integrated into routine walk-in visits. The percentage of visits performed by DIS increased from 3% in 2014 to 45% in 2019. Median duration on PrEP use was 11 months. PrEP discontinuation was associated with non-Hispanic black race/ethnicity [hazard ratio (HR) 1.34, 95% confidence interval (CI) 1.02 to 1.76], age <20 years (HR 2.17, 95% CI: 1.26 to 3.75), age between 20 and 29 years (HR 1.55, 95% CI: 1.06 to 2.28), and methamphetamine use (HR 1.98, 95% CI: 1.57 to 2.49). The clinic had 750 patients on PrEP in the final quarter of 2019.

Conclusions: A demedicalized SHC PrEP model that task shifts most operations to DIS can provide PrEP at scale to high priority populations.



Preexposure prophylaxis (PrEP) is an essential part of the National HIV/AIDs Strategy for the United States and the Ending the Epidemic Initiative.[1,2] Although PrEP use has increased since it was first approved by the Food and Drug Administration in 2012, a Centers for Disease Control and Prevention (CDC) estimated that only 18% of the 1.2 million Americans with indications for PrEP were prescribed it in 2018.[3] There are large gaps in access, uptake, adherence, and retention in PrEP among groups at high risk for HIV acquisition, including marked racial/ethnic disparities.[4]

Sexual health clinics (SHCs) have the potential to play a critical role in increasing PrEP use in high-risk populations, including those who are uninsured. These clinics are widely distributed throughout the United States and in a number of other high-income nations and provide services to many patients for whom PrEP is recommended, including men who have sex with men (MSM), transgender persons who have sex with men (TGSM), patients diagnosed with a sexually transmitted infection (STI), and the sex partners of persons with HIV.[5,6] Moreover, SHCs are linked to a wider public health system of STI/HIV surveillance and outreach that has the potential to reach even larger and more diverse networks of persons at risk for HIV.[5,7]

Many US SHCs now provide PrEP. An ongoing national CDC learning collaborative includes 31 SHCs, 24 (77%) of which provide PrEP prescriptions to patients (CDC program data, personal communication). Although different models for PrEP implementation in SHCs have been described,[8,9] best practices for real-world integration of PrEP services into SHCs are ill defined. Ideally, PrEP should be readily accessible to patients, affordable, and implemented without disrupting other SHC services or placing unsustainable new demands on clinician time.[9–11] We describe our experience implementing a demedicalized model of PrEP between 2014 and 2020 in the Public Health- Seattle & King County (PHSKC) SHC located in Seattle, WA.