56 Dean Street, a combined sexual health and HIV clinic in Soho, London ‒ part of Chelsea and Westminster NHS Foundation Trust ‒ is the busiest clinic of its type in Europe with around 12,000 patient attendances per month. We interviewed Dr Gary Whitlock, one of seven consultant physicians in sexual health and HIV medicine practising at the clinic to find out more about what makes Dean Street so successful.
UNIVADIS: Could you describe the set-up of the clinic at Dean Street?
DR. WHITLOCK: Like all UK-based sexual health clinics, 56 Dean Street provides comprehensive assessment and treatment of sexual health and contraception including the management and follow-up of those living with HIV and other blood-borne viruses such a hepatitis B and C. One of the most important aspects of our clinic is that it’s multidisciplinary – there are doctors, nurses, healthcare assistants, forming a team with a mixture of skillsets. We provide psychological support that is tailored to our patients, such as one-to-one sessions with health advisers and we are open six days a week and most evenings until 7pm.
UNIVADIS: The clinic has adopted a ‘Getting to Zero’ public health initiative which endeavours to achieve zero new infections, zero deaths due to HIV/AIDS, and zero stigma for people living with HIV – where are you in achieving this and what strategies have you employed that have brought you closer to your goal?
DR. WHITLOCK: Over the past few years, we’ve seen a significant drop in new HIV diagnoses in England generally and in particular, our clinic. We believe that this is attributable to a combination-prevention approach as opposed to any single strategy.1
At 56 Dean Street, we were early adopters of ‘treatment as prevention’. Historically, HIV medication was only initiated at a point where the immune system had deteriorated, which meant that people may have waited quite some time before starting anti-retroviral therapy (ART). ‘Treatment as prevention’ promotes ART initiation as soon as possible and according to patients’ needs in order to achieve rapid HIV viral load suppression and so preventing HIV transmission, ultimately acting as a public health prevention measure. We now know that people on effective HIV treatment cannot pass the virus on to others – these findings were recently advocated by the international U=U (undetectable equals untransmissible) campaign.
Another key strategy that we champion is facilitating people to test regularly for sexually transmitted infections (STIs). Public Health England currently recommends that gay men, in particular those who change partner regularly, test every 3 months. It is not uncommon at Dean Street to see such individuals – historically, they carry a higher risk of acquiring all STIs including HIV and as such, it is imperative that they test regularly to facilitate early detection and subsequent treatment. We set up Dean Street Express 5 years ago, which was initially a service where asymptomatic individuals could rapidly test for STIs such as chlamydia, gonorrhoea and bloodborne viruses including HIV. Dean Street Express was designed to provide an efficient service: users perform their STI testing in about half an hour, receive their results within 6-8 hours and receive treatment within 48 hours. This service was highly effective in getting more people to test and we would typically see up to 400 people testing per day. This approach came with its challenges. In order to run a service that was feasible, we then had to limit the number of available slots to ensure the delivery of a high-quality service. When Dean Street Express first opened, we initially saw a rise in the number of HIV diagnoses in parallel with increasing testing numbers. After peaking in late 2015, the number of people newly diagnosed HIV-positive at our service has consistently fallen.
Following 56 Dean Street’s increased case-finding of new HIV diagnoses in 2016 (half of which had acute HIV infection with very high HIV viral loads at diagnosis), we introduced a new service to offer patients the option to discuss starting ART within 48 hours of their new HIV diagnosis. Previously, the offer of ART initiation was routinely performed 14 days after a confirmatory HIV diagnosis. In addition to facilitating regular HIV testing that enables us to pick up recently acquired HIV infections, rapid ART initiation achieves faster viral suppression (known as test-and-treat) and reduces onward HIV transmission. As a result, we believe that encouraging people to test more frequently and getting them on to ART earlier has been a valuable strategy for reducing HIV.
56 Dean Street was also a very early advocate of oral HIV pre-exposure prophylaxis (PrEP), an oral tablet that has been shown to be highly effective at preventing HIV acquisition in those at risk. In 2015, we set up a service to provide PrEP at cost price for individuals who wanted to purchase it from our clinic. Around this time, there was huge community movement and interest in PrEP, including patient advocacy groups which enabled the online purchase of generic PrEP such as IWantPrepNow. During 2015, we saw a rise in the number of users at 56 Dean Street who were using generic PrEP. As a consequence, like other London STI clinics, in 2016 we took the decision to set up a PrEP monitoring service at 56 Dean Street for anyone using oral PrEP. PrEP has been highly useful and real-world data have confirmed its efficacy when used optimally.2 Personally, I believe that PrEP has been integral in revolutionising HIV risk and the stigma associated with it – we’ve seen very few cases of PrEP failure. There is a debate as to whether PrEP is fuelling the rise we’re seeing in STIs – however, PrEP comes with a need for more frequent monitoring which provides us with greater opportunity to detect STIs, often when they are asymptomatic.
Around 5 years ago, we identified risk factors for gay men visiting our clinic who had the highest risk of developing HIV in the next 12 months (approximately 10% risk) such as early syphilis infections, rectal gonorrhoea and chlamydia and recent post-exposure prophylaxis for HIV. We then created Dean Street Prime, a service that invites individuals with a high risk of acquiring HIV to sign up to web-based information and regular text updates. Dean Street Prime provides information on HIV combination-prevention options such as PrEP and other pertinent aspects of sexual health. Thus, targeting high-risk individuals and encouraging them to adopt combination strategies is key. At Dean Street, all these campaigns have worked very well and we believe that the decreasing rates of HIV are due to a combination approach. We would therefore encourage all sexual health services to provide patients with the tools to choose which combination-prevention methods work best for them by offering them as many options as they possibly can.
UNIVADIS: What are some of the practical obstacles to eradicating HIV?
DR. WHITLOCK: Not everyone will adopt all or any combinations of HIV transmission prevention and the prevention methods they use may change over time, so I think it’s important to encourage people to maintain their prevention methods over time. That’s why with Dean Street Prime, where individuals are using no prevention strategies, we advise them to test monthly for HIV and whenever they feel unwell.
It’s important to remember that there are always new people who are at risk coming in to the clinic. We may educate the people attending our services, but what about the pool of new people? There is no practical way of disseminating your prevention strategies if they have never attended your clinic before. In addition, it’s evident that there are issues among the wider population regarding knowledge on HIV transmission and we’re uncertain as to how we can better engage younger people about their risks. This prompted us to create our Plan Zero tool on our clinic website (dean.st/zero), a web-based education tool about HIV prevention. We are endeavouring to engage people in the community further through social media (for example, the Public-Health-England-funded web-serial on the 56 Dean Street YouTube channel (https://www.youtube.com/c/56DeanStreetOfficial), ‘The Grass is Always Grindr’, which contains health promotion messages)
We continually review our data and we are now concerned that younger gay men in particular are at greater risk for acquiring HIV and may be unable to access the relevant services and medical care that they need. For that reason, we’re looking at ways to encourage this population to access 56 Dean Street.
UNIVADIS: What are some of the factors required to establish a successful clinic like Dean Street?
DR. WHITLOCK: The first step is ensuring the clinic is set up in the most optimal location. The rationale behind our location was to be situated where we knew there was undiagnosed HIV. Around the time of our clinic move into Soho, London 10 years ago, published data suggested that there were roughly one in 20 gay men in Soho bars who had undiagnosed HIV infection.4
We also wanted to make the centre appear less clinical – a key learning for other testing centres could be to ask the target audience where they would prefer to test. Choosing a suitable clinic location that’s also easily accessible and conducive to testing is all very positive and doesn’t necessarily need to be costly. Clinics can provide online education for patients at a low cost; web-based interventions such as Dean Street Prime can be adopted by other sexual health services. Our rapid ART initiation service was set up with minimal changes to the clinic capacity.
One difficulty with facilitating people to test for STIs is the increased funding required to pay for those tests. A possible way to reduce the impact of this is for services to identify and prioritise at-risk groups.
UNIVADIS: PrEP use is increasing in Western Europe – as of early 2017, general practitioners in France were authorised to renew prescriptions for PrEP. Do you have any advice for other disciplines who are beginning to become involved in this process?
DR. WHITLOCK: I think it is vital for people who are able to prescribe or renew PrEP to understand the population they are treating. There is a danger in medicalising PrEP – the holistic support needed to treat disease may not always be offered and as with any other disease, this is indispensable. Ultimately, implementing a multidisciplinary approach to manage HIV is the best way forward; we have to ensure that the whole team is involved in decision making and shaping of the service to improve outcomes for our patients.