56 Dean Street 由護士主導的 PrEP 供應
http://www.thelancet.com/hiv/doi.org/10.1016/S2352-3018(22)00364-2/2022 年 12 月 20 日在線發布
護士主導的分娩已被建議作為在全球範圍內擴大 HIV 暴露前預防 (PrEP) 的策略。我們描述了成功實施多學科團隊方法來提供 PrEP，在倫敦市中心的一家性健康診所迪安街56號（56 Dean Street）使用共同配制的口服富馬酸替諾福韋二吡呋酯 (tenofovir disoproxil fumarate) 和恩曲他濱 (emtricitabine) 。
護士和專職醫療人員（例如健康顧問和藥劑師）可以啟動 PrEP 並使用法律框架（稱為「患者團體指引」）監測服用者。 每週一次由顧問主導的門診服務支持多學科團隊為那些有複雜需求、富馬酸替諾福韋地索普西和恩曲他濱有禁忌症或難以服用 PrEP 的人提供 PrEP。
我們使用從電子病歷中常規收集的數據（包括諮詢日期、年齡、性別、郵政編碼和種族）提取了一個匿名的諮詢數據集，其中 PrEP 於 2021 年在 56 Dean Street 開出處方。 作為我們收集匿名常規臨床數據的服務評估，不需要倫理批准。
2021 年有 40,950 次 PrEP 諮詢。其中，37,189 次 (90·8%) 由護士完成。PrEP 諮詢面向 22, 938 人。 98·2% (22,522) 為男性，70·9% (16,255) 為白人，84·2% (19,306) 居住在倫敦； 44·2% (10,140) 年齡在 25-34 歲之間（表）。
表：在2021年加入56 Dean Street性健康診所之個案的社會人口學特徵
（＊僅有二元性別認同可以登錄，但個人可自由選擇與其最覺得相符的性別認同）
這些數據使我們能夠提供有關 PrEP 用戶的有意義的信息，並顯示主要由護士提供 PrEP 的任務分擔可以提供大量的 PrEP，這是醫生無法單獨提供的。我們注意到在英國，「患者團體指引」允許護士主導的 PrEP 提供，而其他地方缺乏此類工具是實施非醫生主導服務的障礙。
為了進一步為有需要的人推廣 PrEP，56 Dean Street 還鼓勵從所有具感染 HIV 風險的個人開始，在選擇性退出的基礎 (opt-out basis) 上，與被診斷患有細菌性直腸傳播感染的男男性行為者、以及所有開具暴露後預防處方的個人。隨著 PrEP 普及率的提高，我們為服務不足的群體努力擴大其參與範圍，包括有感染 HIV 風險的婦女、跨性別者、流動人口和以前可能沒有參加過性健康服務的少數族裔群體，同時也支持那些 PrEP 順從性差的人。
GW 已向 ViiV Healthcare 和 Gilead 諮詢或收取演講費。 VT 已獲得出席 ViiV Healthcare 會議的讚助。
所有其他作者聲明沒有競爭利益。
Dean Street Collaborative Group 包括 Keerti Gedela、Nicolo Girometti、Frances Lander、Alan McOwan、Diarmuid Nugent、Sheel Patel、Tara Suchak、Vicky Tittle 和 Gary Whitlock。 *Gary Whitlock、Jon Clark、Vicky Tittle 代表 Dean Street Collaborative Group gwhitlock@nhs.net 56 Dean Street, Chelsea and Westminster Hospital NHS Foundation Trust, London, W1D 6AQ, UK
Nurse-led PrEP provision at 56 Dean Street
http://www.thelancet.com/hiv/doi.org/10.1016/S2352-3018(22)00364-2/Published Online December 20, 2022
Nurse-led delivery has been suggested as a strategy to scale up HIV pre-exposure prophylaxis (PrEP) globally.1 We describe the successful implementation of a multidisciplinary team approach to PrEP provision, using co-formulated oral tenofovir disoproxil fumarate and emtricitabine at 56 Dean Street, a sexual-health clinic in central London.
Nurses and allied health professionals (such as health advisors and pharmacists) can initiate PrEP and monitor those taking it using a legal framework, known as Patient Group Directions. A weekly consultantled outpatient service supports the multidisciplinary team with PrEP provision for those with complex needs, contraindications to tenofovir disoproxil fumarate and emtricitabine, or difficulty taking PrEP.
We extracted an anonymised dataset of consultations in which PrEP was prescribed in 2021 at 56 Dean Street using routinely collected data from electronic patient records including the date of consultation, age, gender, postcode, and ethnicity. As a service evaluation in which we collected anonymised routine clinical data, ethical approval was not required.
There were 40 950 PrEP consultations in 2021. Of these, 37 189 (90·8%) were done by nurses. The PrEP consultations were for 22 938 individuals. 98·2% (22 522) were men, 70·9% (16255) were White ethnicity, and 84·2% (19306) resident in London; 44·2% (10 140) were aged 25–34 years (table).
These data allow us to provide meaningful information about PrEP users and show that task-sharing of PrEP provision predominantly by nurses can provide PrEP at high volume, which could not be delivered by medical doctors alone.1 We are mindful that in the UK, Patient Group Directions allow for nurse-led PrEP provision, and the absence of such a tool elsewhere is a barrier to the implementation of non-doctor-led services.
To further promote PrEP for those at need, 56 Dean Street also encourages initiation for all individuals at risk of HIV, on an opt-out basis to men who have sex with men diagnosed with a bacterial rectal sexually transmitted infection, and to all individuals prescribed post-exposure prophylaxis. As PrEP uptake increases, we strive to broaden engagement among underserved groups including women at risk of HIV, trans people, migrant populations, and minoritised ethnic groups who might not have attended sexual-health services previously, while also supporting those with poor PrEP adherence.4,5
GW has consulted for or received speaker fees from ViiV Healthcare and Gilead. VT has received sponsorship for attendance at a conference from ViiV Healthcare.
All other authors declare no competing interests.
The Dean Street Collaborative Group comprises Keerti Gedela, Nicolo Girometti, Frances Lander, Alan McOwan, Diarmuid Nugent, Sheel Patel, Tara Suchak, Vicky Tittle, and Gary Whitlock. *Gary Whitlock, Jon Clark, Vicky Tittle on behalf of the Dean Street Collaborative Group gwhitlock@nhs.net 56 Dean Street, Chelsea and Westminster Hospital NHS Foundation Trust, London, W1D 6AQ, UK