Form 0920-22GA Aims 1&2 Clinic Assessment (every 6 months)

[NCHHSTP] Expanding PrEP in Communities of Color (EPICC)

Att_4s_Aim1&2ClinicAssessmentEvery6Months[1]

Aims 1&2 Clinic Assessment (every 6 months)

OMB: 0920-1423

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Form Approved

OMB No. 0920-New

Expiration Date: XX/XX/XXXX










Expanding PrEP in Communities of Color (EPICC+)


Attachment 4s

Aim 1&2 Clinic Assessment Every Six Months






















Public reporting burden of this collection of information is estimated to average 90 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-New)


Clinic Assessment Every 6 months

*Note this assessment does not need to be completed for satellite or affiliate clinics.


Instructions: Clinic staff should complete this assessment every 6 months during data collection starting 6 months after the baseline clinic assessment is completed.


Clinic Information

  1. Name of clinic

  2. Address

  3. Days and hours of operation

  4. What mode of healthcare delivery is your clinic currently using?

    1. In-person

    2. Telemedicine

    3. Both

      1. Estimated percentage of healthcare delivery that is in-person

      2. Estimated percentage of healthcare delivery that is telemedicine (includes both telephone and teleconferencing)

  5. Number of clinical providers1

  6. Number of clinical providers1 who prescribed PrEP in the last 6 months

  7. Does your clinic have an in-house pharmacy?

    1. If yes, does it dispense PrEP medications?

  8. Does your clinic provide transportation support (e.g., gas vouchers, medical transport) for PrEP appointments?


PrEP Prescriptions2

  1. PrEP prescriptions last 6 months


PrEP Regimen

All Clients

Clients 18-39

years

Men who have sex with men

Black MSM 18-39

years

Hispanic/Latino MSM 18-39 years


Shape1

1 Persons with capacity to prescribe medications

2 Count of all prescriptions provided, may exceed number of PrEP patients as a patient may receive >1 type of PrEP in the time period





(MSM) 18-

39 years



F/TDF: Emtricitabine co- formulated with tenofovir disoproxil fumarate (trade name Truvada®),

prescribed daily






F/TDF: Emtricitabine co- formulated with tenofovir disoproxil fumarate

(generic), prescribed daily






F/TAF: Emtricitabine co- formulated with tenofovir alafenamide (trade name

Descovy®)






F/TDF: Prescribed for

intermittent use (2-1-1 or event-driven PrEP)






CAB: Cabotegravir

intramuscular injections







Clinical Services

  1. HIV tests3 last 6 months (excluding testing for persons with previously diagnosed HIV infection)


HIV Test

All Clients

Clients 18-39

years

Men who have sex with men (MSM)

18-39 years

Black MSM 18-39

years

Hispanic/Latino MSM 18-39 years




Shape2

3 Count of all HIV tests provided, may exceed number of patients tested as a patient may receive >1 HIV test in the time period


Laboratory-based antigen/antibody

tests






Point-of-care antigen/antibody

tests






Laboratory-based viral

load/nucleic acid tests






Point-of-care viral

load/nucleic acid tests







  1. Does your clinic employ a PrEP navigator or anyone on staff whose responsibilities include helping clients obtain and continue with PrEP prescriptions?

    1. If yes, how many?

  2. What financial assistance programs does your clinic provide (check all that apply, add additional to bottom of table)

Financial assistance program

Yes

Income-based sliding scale for clinical services


Assistance with enrollment in federal PrEP access programs (i.e., Ready Set PrEP)


Assistance with enrollment in drug manufacturer PrEP access programs


Other, please specify



  1. What components are included in typical PrEP initiation and follow-up visits? (check all that apply, add additional to bottom of table)


PrEP Initiation Visit

(Considering or starting PrEP)

PrEP Follow-

up visit

Screening for potential to benefit from PrEP

to reduce the risk of acquiring HIV



Counseling about all available PrEP options




Providing printed patient materials about

selected PrEP regimen



Counseling about effect of adherence on

PrEP efficacy



Adherence support



Assessment of insurance status



Assistance with insurance enrollment if un-

or under-insured



Assistance with enrollment in PrEP access

programs (e.g. Ready Set PrEP) if needed



HIV testing



Other STI testing (please specify)



Other clinical testing (please specify)



Other (please specify)




  1. Does the clinic have a protocol for timing of PrEP follow up visits? If not, what is the range of time between the initial PrEP visit and the first follow up visit?

  2. What is the process for scheduling follow-up visits? Is it clinic-initiated or patient-initiated?

  3. Does your clinic have specific procedures for engaging (re-engaging) with patients who don’t return for PrEP follow-up visits?

    1. If yes, please describe

  4. What PrEP adherence support does your clinic provide? (check all that apply, add additional to bottom of table)

PrEP adherence support

Yes

Printed patient materials


Links/information about online materials


Pill boxes


Electronic medication monitors


Automated medication reminders


Peer-to-peer adherence support



SMS/text reminders from clinic staff


Motivational interviewing-based intervention


App/smartphone-based adherence support


Other (describe)



  1. What types of educational materials does your clinic provide to clients? (check all that apply, add additional to bottom of table)

Educational materials

Print

Online

None

Other, please

specify

Materials that address sexual health topics





Materials that address sexually transmitted

infections





Materials that specifically address HIV





Materials that specifically address PrEP





Other (describe)






  1. Are cabotegravir intramuscular injections for PrEP available at your clinic?

  1. If yes, then please complete cabotegravir provider section

  2. If no, then please complete cabotegravir non-provider section



Cabotegravir provider:

  1. Does your clinic keep doses of cabotegravir available (in stock onsite)?

    1. If yes, how does your clinic order and maintain your supply? How many doses do you maintain in stock onsite?

      1. Do stock outs occur? If yes, how frequently?

      2. Do shortages occur? If yes, how frequently?

  2. Do any patients pick up the drug at a pharmacy?

  1. If yes, how is it prescribed? Does the clinic call/transmit the prescription to the pharmacy? Does the patient take a written prescription to the pharmacy?

  2. How do patients pay for the drug if they don’t have prescription benefits?

  3. If patients pick up the drug at the pharmacy, does the pharmacist administer the injection?

    1. If yes, does the pharmacist charge an injection fee?

  1. For the initial prescription, what is the average time between cabotegravir prescription to administration of the cabotegravir dose?

  1. If applicable, how does it vary by stocked drug in the clinic compared to picking up the drug at a pharmacy?

  1. How is the patient billed for the injection? Is there a charge for the drug? A separate charge for the injection?


Cabotegravir non-provider:

  1. Why does your clinic not currently provide cabotegravir?

  2. If you are planning to provide it, when do you expect to make it available?

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorTanner, Mary (CDC/DDID/NCHHSTP/DHP)
File Modified0000-00-00
File Created2023-11-01

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