key: cord-0954895-vdp8od6m authors: Hoagland, Brenda; Torres, Thiago S.; Bezerra, Daniel R.B.; Geraldo, Kim; Pimenta, Cristina; Veloso, Valdilea G.; Grinsztejn, Beatriz title: Telemedicine as a tool for PrEP delivery during the COVID-19 Pandemic in a large HIV Prevention service in Rio de Janeiro-Brazil date: 2020-05-31 journal: Braz J Infect Dis DOI: 10.1016/j.bjid.2020.05.004 sha: 3ed31650b6271a3d4f639eb6a5a4a02500f05568 doc_id: 954895 cord_uid: vdp8od6m Abstract COVID-19 public health responses such as social distancing and community containment measures protocols are critical to preventing and containing the spread of coronavirus. Brazil accounts for almost half of Latin American HIV cases and Rio de Janeiro is the city with the second largest number of AIDS. Clinical appointments and pharmacy antiretroviral refills may be impaired due to restricted traffic and possible lockdowns, preventing people living with HIV and those using PrEP from accessing needed antiretrovirals. We hereby describe the telemedicine procedures implemented in a large PrEP delivery in Rio de janeiro in the context of the COVID-19 pandemic. At the initial teleconsultation, individuals undergoe HIV rapid testing and are assessed by phone for PrEP related procedures. Individuals receive a digital prescription to retrieve a 120-day PrEP supply plus two HIV self-test kits. Subsequent follow-up teleconsultations will be performed remotely by phone call, including instructions for the HIV self-test performance, which results are to be sent using a digital picture. Participants will attend the service only for PrEP refill. The use of telemedicine procedures is being effective to avoid PrEP shortage and reduce the time PrEP users spend at the service during the COVID-19 pandemic and social distancing recommendations. Janeiro is the city with the second largest number of AIDS. Clinical appointments and pharmacy antiretroviral refills may be impaired due to restricted traffic and possible lockdowns, preventing people living with HIV and those using PrEP from accessing needed antiretrovirals. We hereby describe the telemedicine procedures implemented in a large PrEP delivery in Rio de janeiro in the context of the COVID-19 pandemic. At the initial teleconsultation, individuals undergoe HIV rapid testing and are assessed by phone for PrEP related procedures. Individuals receive a digital prescription to retrieve a 120-day PrEP supply plus two HIV self-test kits. Subsequent follow-up teleconsultations will be performed remotely by phone call, including instructions for the HIV self-test performance, which results are to be sent using a digital picture. Participants will attend the service only for PrEP refill. The use of telemedicine procedures is being effective to avoid PrEP shortage and reduce the time PrEP users spend at the service during the COVID-19 pandemic and social distancing recommendations. The HIV pandemic continues to affect a large number of individuals worldwide. In 2018, 37.9 million people were living with HIV and 1.7 million were newly infected. During the same period the Latin America region had 1.9 million accumulated cases and 100,000 new HIV infections. 1 Brazil accounts for almost half of Latin American HIV cases, with a disproportional prevalence of infection among key populations, such as gay, bisexual and other men who have sex with men (MSM) (18%), and transgender women who have sex with men (TGW) (31% ). [2] [3] [4] [5] In 1996, the Brazilian government System (SUS). 6 One month later, the Implementation PrEP demonstration project (ImPrEP), a cross-country study conducted in Brazil, Mexico and Peru, was initiated aiming to assess safety and feasibility of same day initiation of oral PrEP for MSM and TGW at high risk for HIV infection. 7 ImPrEP is coordinated by the Instituto Nacional COVID-19 public health responses such as social distancing and community containment measures protocols are critical to preventing and containing the spread of COVID-19, and were adopted in Brazil since March 2020 to avoid the collapse of the health system. Yet, these important measures may also affect the HIV prevention and J o u r n a l P r e -p r o o f care continuum, with reduced access to HIV testing, linkage to prevention and care services and ART or PrEP initiation and maintenance. Clinical appointments and pharmacy antiretroviral refills may also be impaired due to restricted traffic and possible lockdowns, preventing people living with HIV (PLWH) and those on PrEP from accessing needed antiretrovirals and reduce their likelihood of prevention and treatment adherence. 8 Moreover, individuals may feel afraid or uncomfortable to leave their homes due to risk of COVID-19 infection. As such, tailored strategies that minimize disruptions in access and adherence to antiretrovirals for HIV prevention and treatment are urgent. The Brazilian Federal Council of Medicine (CFM) defines teleconsultation as a "remote medical consultation, mediated by technologies, with doctor and patient located in different geographical spaces". 9 During this pandemic, the CFM recognized the possibility and ethics of using telemedicine. 10 In addition, the Brazilian Ministry of Health has extended PrEP dispensation from 90-to 120-day supplies. 11 As a consequence, health services offering PrEP have been required to implement a new framework to meet the current demands. After this initial teleconsultation, until the social containment is released, all subsequent follow-up teleconsultations will be performed remotely by phone call, including instructions for the HIV self-test performance and for sending the results using a digital picture. Participants will attend the service only to collect their PrEP refill, significantly reducing the time spent at the service and the social contact. Unfortunatelly, we were unable to implement home delivery of the PrEP supply, which would have been ideal during the social distancing period, but unnafordable. PrEP users are also instructed to make phone contact in-between visits in case of symptoms of sexually transmitted infections (STI) or other health problems related to PrEP medication. Since the implementation of the telemedicine procedures in March 23, 2020 until May 08, 2020, 331 participants completed the telephone consultation and the initial teleconsultation. The average time spent at the service was reduced in two hours (from three hours to one hour). We are in the process of collecting structured acceptability data from all individuals who had the initial teleconsultation. So far, most of the participants are reporting to be very satisfied with the new procedures. Despite our preliminary optimistic results, the implementation of telemedicine at other PrEP services in Brazil or other middle-income countries may face constrains. First, although cell phones are widely available, 12 Brazil and other LMIC face huge social disparities, that will become even more profound during the COVID-19 pandemic and could preclude cell phone and internet availability. Second, HIV self-test availability and acceptability should be considered. In a web-based survey conducted in 2018 with more than 11,000 Brazilian MSM, 44% were willing to use HIV self-test but 87% of them considered the post-HIV test counselling support important. [13] [14] [15] Thus, we reinforce the need of trained staff support during the virtual visit. Lastly, lack of regulations on telemedicine and HIV self-testing could forbid the implementation of these procedures in other low-and middle-income countries. In conclusion, the use of telemedicine procedures in a large PrEP service is being effective to avoid PrEP shortage and reduce the time PrEP users spend at the service during the COVID-19 pandemic and social distancing recommendations. Preliminary data showing high acceptability is an indicator that telemedicine procedures could be maintained after COVID-19 pandemic and should be considered by other PrEP services. Screening by phone call using a brief questionnaire for suspect COVID-19 symptoms (1-day prior to semi-virtual visit) Instructions for home quarantine and use of condoms consistently during off-PrEP period. Daily phone call until the end of symptoms Unveiling of HIV dynamics among transgender women: a respondent-driven sampling study in Rio de Janeiro, Brazil. The Lancet HIV HIV prevalence among men who have sex with men in Brazil: results of the 2nd national survey using respondent-driven sampling Epidemiology of HIV in Latin America and the Caribbean: Current Opinion in HIV and AIDS The HIV epidemic in Latin America: accomplishments and challenges on treatment and prevention Brazil begins PrEP roll-out on World AIDS Day. World Health Organization Oral abstracts of the 10th IAS Conference on HIV Science Maintaining HIV care during the COVID-19 pandemic RESOLUÇÃO CFM n o 2.227 OFÍCIO CFM N o 1756/2020 Willingness to use HIV selftesting among MSM from Brazil Factors Associated With Willingness to Use Pre-Exposure Prophylaxis in Brazil, Mexico, and Peru: Web-Based Survey Among Men Who Have Sex With Men Factors associated with PrEP awareness according to age and willingness to use HIV prevention technologies: the 2017 online survey among MSM in Brazil Thanks to Unitaid's funding and supporting this project. Unitaid accelerates access to innovative health products and lays the foundations for their scale-up by countries and partners. Unitaid is a hosted partnership of the WHO.J o u r n a l P r e -p r o o f Screening for COVID-19 symptom questionnaire and body temperature measurement No COVID-19 symptoms HIV Provision of mask, prescription (relive symptoms) and 14-day medical certificate Post-HIV test counselling by phone call; schedule face-to-face visit for HIV confirmatory test;PrEP temporarily suspended.Provision of digital prescription to retrieve a 120-days PrEP supply plus two HIV self-test kits at the pharmacy within 72h at the service pharmacy. Next visit is scheduled (remote teleconsultation until social containment is released).Provision of antiretroviral prescription and medical assessment by phone call within 30 days. If good adherence, provision of digital prescription. If not, presential visit is scheduled.