IMPLEMENTATION IN THE REAL WORLD: NURSE-LED UK INJECTION CLINICS

Below are examples of three nurses implementing Vocabria and Rekambys long-acting injectables across the UK.* They’ve included details which they found helpful for setting up their HIV injectable clinics or for delivering the injections in the community. Please refer to the SmPCs before administering.^[1,2]

Michelle Mussard

Community Clinical Nurse Specialist, HIV community team in Liverpool

Case Study 1: Vocabria and Rekambys administered in the community

A day in the life of: Michelle, HIV Community Clinical Nurse Specialist

Who I am and where I work:

My name is Michelle Mussard and I work as part of a HIV community team as a Community Clinical Nurse Specialist. We deliver care to patients living with HIV in the community who have complex needs and find it difficult to attend hospital. Whilst our cohort of patients have physical or mental health reasons why they cannot attend hospital, the majority of our caseload also feel socially stigmatised and they require sensitive and discreet care in their own homes.

At this time, our caseload consists of about eighty patients and we currently have seven people receiving Vocabria and Rekambys.

How we administer Vocabria and Rekambys:

For all approved patients receiving Vocabria and Rekambys in the community, they have their injections administered in their own homes, in line with national and local guidelines and policies allowing for community administration.^[3] In order to plan around our patients’ complex lives, we use both paper and electronic diaries and we set and send frequent reminders for them.

The week before the injection visit is due, we submit a prescription to the hospital pharmacy. We call our patients and book them in for a date and time that is convenient for them. I send a text reminder the day before the home visit, as well as texting them on the day of the appointment. When they confirm the appointment, I take Rekambys out the fridge (this is used within 6 hours of removal from the fridge).^[2] We do inform our patients that there is a (+/-) 7 day window from their treatment target date,^[1,2] but we try not to encourage the use of this.

We have found that it is best to have two nurses available when administering Vocabria and Rekambys in a person’s home. Sometimes there have been distractions in the home like pets or other members of the family. Some people live very hectic lives and no two environments are the same. Having two nurses enables one to focus on the administration of the injections and the other to focus on securing clean areas to administer. Delivering injections at home can prove difficult. The environment does not match that of a clinic room. There may not be a flat clean surface available for the patient to lie down all the time. It is vital to carry out (and document) a risk assessment, and work with the environment available. If needed, we would also obtain any routine bloods, like viral load monitoring, during the visit. If a patient was to have an adverse reaction to the medicine, we do have our nursing bag so we can carry out any observations needed (it is recommended to stay with the patient and observe them post injection for at least 10 minutes).

What’s next:

So far delivering long-acting injectables in the community setting has proven successful. Patients who had issues with taking daily ART have reported a much better quality of life and say “they can now focus on their life” rather than worrying if they have swallowed their tablets every day. Our process works for our patients and us. As we see more people’s HIV treatment being switched to long-acting injections, I am confident we can manage larger numbers of people receiving them in the community.

Top tips

As we are out in the community, it’s essential we have everything we need with us. In our nursing bag we have:

Vocabria and Rekambys boxes (ensuring Rekambys is out the fridge no more than 6 hours prior to injection)
Laptop (for prescription and documentation)
PPE (including gloves, masks, hand gel)
Observation equipment/ venepuncture equipment
Blood forms and vials
Supply of 2-inch needles (in case the patient has a high BMI >30 kg/m²)
Adrenaline
Sharps box
Lone worker device

Christina Antoniadi

Senior Staff Nurse, large HIV clinic in London

Case study 2: Vocabria and Rekambys administered in a large HIV clinic

A day in the life of: Christina, Senior Staff Nurse
Who I am and where I work:

My name is Christina Antoniadi and I am a Senior Staff Nurse in a large HIV clinic in London. Our HIV injectable service which is nurse-led, focuses on the administration of the injectable treatment. We also use an app that allows service users, who wish to opt in, to book and re-schedule their appointments, get access to their blood results and notifications that can be tailored according to their needs (manual and automatic). The injections are currently being delivered by staff (band 5) and senior staff (band 6) nurses, and training has also been provided to nurse practitioners (band 7) and advanced nurse practitioners (band 8) working in the clinic.

How we administer Vocabria and Rekambys:

After people have been approved through the virtual clinic for the long-acting injectable therapy (and they have discussed the change with their physician and pharmacist) they are then put in contact with a nurse, such as myself, in our clinic. During their first visit we discuss the app we can use for appointment booking and bloods, the treatment (including potential side effects) and we give them the patient information leaflet and our emergency contact details. During their first appointment I also encourage the patient to write down any questions they might have so we can answer them at the next visit. We then book in their injection appointments for 6 months based on their target date for injections (this can be done with or without the app if the person prefers). The app enables notifications to be sent the week before their treatment target date. The service-users are encouraged to book an appointment with their doctor every 6 or 12 month for a medical review in line with BHIVA guidelines in addition to their injection visits.^[4]

On the first injection visit (after the month of oral lead in, or if the person is starting with injections) I check with the patient that they are ready for the injections. I start the visit with the standard checks and blood samples, in line with local and national guidance, we check their viral load and/or liver/renal function at every injection visit.^[3] For all other bloods we follow the BHIVA monitoring guidelines and adjust according to clinical evaluation and assessment.^[4]Then I ensure they have their future appointments booked, confirm their concomitant medications, ask them how they are feeling about the injections, and discuss any potential side effects. This enables the patient to calm down and ensures I have answered all their questions before initiating the injections. I ask them to lie down and to choose which side we are doing first. I identify the spot and confirm it with them. I follow the trust advice using ventrogluteal injections and I use the V technique to identify the right spot and the z-track technique to administer each injection on each side. After I administer the injections and I ask them to stay in the waiting room for 10-15 minutes to monitor for any potential side effects. If the patient’s do experience side effects (during the first appointment or between appointments) I provide management advice if I am asked.
Opportunities for efficient service delivery:

Ensure good co-ordination with the MDT:
We use a shared calendar and a traffic light system to co-ordinate the work efficiently among the MDT. The patients’ appointments are added into the shared calendar by the nurse who sees the patient and are marked as red. We have two assigned doctors who prescribe once a week and mark the appointments in the calendar as orange. The pharmacy screens the prescriptions and dispenses the medication. When the patient comes in and has their injection, the nurse who has seen them marks the calendar appointment in green.Using the app ensures our patients have the flexibility to re-schedule their appointments. This inevitably means that once a week a nurse needs to check and update the calendar and the charge nurse needs to ensure one member of staff trained on injectables is assigned to cover the appointments should the original nurse not be available to deliver the injections. This is particularly important when trained nurses are off sick or on annual leave. Our good coordination has meant we have managed to deliver the injections without needing to re-schedule any appointments while accommodating the best suited solutions for the service users.

Managing missed and late appointments effectively:
Since we have been delivering the HIV injectable clinic we have had 2/3 late appointments in total. The current pathway described in our SOP dictates: On the first instance the nurse assigned to the injectables clinic makes a phone call to ensure the patient is well. If we can’t connect with the patient, we send a push notification (via the app) asking them to book and/or reschedule their appointment. Their doctor is also notified at this stage of the process. This process has worked well so far and every injection had been delivered in the +/- 7 day window from the treatment target date. If further escalation was ever needed, we would be adding them to the lost-to-follow up list. None of our patients have needed oral bridging so far. The app we use helps to keep the patients informed and updated and has helped our process for giving the long-acting injectables.

Top tips

To maximise the patient experience during their visit:

Use relaxation techniques which the patient finds effective, like playing some music or chatting about issues interesting to them to keep them calm.
Allow for time during the appointment with the patient, let them lead the discussion to ensure all their questions are answered.
Don’t be shy in using this appointment to identify other needs of the patient. I have done a number of non-medical prescribing referrals to physiotherapy, dietetic services, women’s and menopause clinic, sexual health clinic, and more, during these appointments.
Be flexible and empathetic. Each patient is different and the interaction with the clinic is an opportunity for growth and development.
If you are uncomfortable administering IM injection your nearest sexual health clinic can help support you with that experience.
Identify upcoming travel/holidays with the patient well in advance to avoid clashes in their and our own schedules (we use a proforma to document this information)

Gaynor Quinn

Clinical nurse specialist, in a small clinic in the Black Country

Case study 3: Vocabria and Rekambys administered in a small sexual health clinic

A day in the life of: Gaynor, Clinical Nurse Specialist
Who I am and where I work:

My name is Gaynor Quinn, a clinical nurse specialist in a small sexual health clinic within the Black Country. We have a small HIV team consisting of three doctors, a pharmacist and a psychologist.

We currently have a caseload of 580 patients living with HIV. At this moment, 27 of these patients have commenced on Vocabria and Rekambys.

How we administer Vocabria and Rekambys

For any approved patients on the long-acting injectables, we have a dedicated HIV injectable clinic on a Wednesday, with on average four patients during this day, and the most in one day being 8 patients. For every visit, we take the opportunity to discuss their general and mental wellbeing, any changes to their medical or sexual history, and any other concerns they may have. We also check their BMI (to determine if we need to use a longer needle for the injections for people with high BMI >30 kg/m²), and we also use these appointments to do their routine monitoring, as required, in line with BHIVA guidance.^[4] Their viral load (VL) will initially be tested at every visit every 2 months. Once the patient has remained undetectable through 4 to 5 injection visits, we have decided that the timing of VL tests will change to every other visit (or every 4 months).

Once the assessment has taken place, the injections are then administered prior to performing any other tests. This allows time to observe for any adverse effects (recommended at least 10 minutes of monitoring after the injections). To ensure Rekambys is at room temperature, this is taken out the fridge 20 minutes before administering (and used within 6 hours).^[2]

Prior to the patient leaving the department, their next appointment is scheduled. This provides an opportunity to identify any prebooked commitments they may have and if bridging methods are required to cover a missed injection visit. Many of the patients prefer to book as many appointments ahead of time as possible which enables them to schedule other commitments around their injection target date.
Opportunities for efficient service delivery:

Use templates for streamlining injection visits and MDT coordination:
Templates have been created on the electronic patient records to easily document the visits and distinguish these appointments from any others. The initial template provides sections to input the MDT details and relevant checks. These include: hepatitis B status (ensuring their status is negative or they are vaccinated where possible), Blueteq completion, previous resistance (to ensure no confirmed or suspected resistance to the NNRTI or INSTI classes), dates of the loading doses, if oral lead in was required and VL results. A further template has been created for each follow-on visit with sections for the injections provided, injection site utilised (dorso or ventrogluteal), blood samples taken, weight and BMI, and any other comments.

Make sure patient appointments are visible and prescription are ready ahead of time:
A whiteboard, located away from public areas, is updated following each patient’s appointment. This provides an “at a glance” overview of when patients are due in and is another way of highlighting if anyone should miss their appointment. Following each appointment, a prescription is also written for their next visit, by ensuring treatment is ready and available.

Ensure appropriate staff cover for the injectable service:
Initially there was only myself and one Health Advisor trained in administering the injections. As the numbers of patients on injections has increased, it has been necessary to train more staff within the department. This ensures complete cover for any absences and holidays so patients do not need to reschedule their appointments.
What’s next:

Over the last 12 months, the delivery of the Vocabria and Rekambys in our clinic has been an ongoing success. It has been a pleasure to see the positive impact it has had on the daily lives and mental/emotional wellbeing of the patients so far. The systems we have in place have proved to work very well for both the clinical staff and the patients, providing a seamless flow to their attendance. I am confident that these processes will continue to support us with the increasing number of patients who are keen to commence on Vocabria and Rekambys in the future.

Top tips

Ensure patients approved are motivated to come to clinic and have good attendance:

An MDT discussion is held regarding each patient prior to commencing injections. Part of this discussion includes a screening process to ensure the patient is likely to have good attendance every 2 months after initiation injections.
Patients are also made aware of the importance of attending on time and how Rekambys can only remain out of fridge for up to 6 hours.
All patients have access to multiple clinic phone numbers, a mobile number they can use to text or WhatsApp and an email address - they have multiple ways to contact in advance should they need to cancel and rearrange.
Each patient also receives an appointment reminder via text and a phone call from reception staff the day before their appointment is due.
Reception staff are also aware to highlight if a patient should cancel their appointment. This provides opportunity to check the patient has rebooked and that they remain within their injection window.

The examples above show there is no one way to deliver Vocabria and Rekambys. They show that each service is unique in how they approach long-acting injectable delivery: from a small clinic all the way through to delivering injections in peoples’ homes. The examples above highlight the amazing work that has gone into building these HIV injectable services by the three nurses. We at ViiV UK would like to thank Michelle, Christina and Gaynor for sharing their best practices of how they have delivered Vocabria and Rekambys for people living with HIV in their care.

Contact your UK ViiV HIV Nurse Specialist Advisor

Identifying people suitable for Vocabria and Rekambys in the real world: Nurse-led patient case studies in the UK

Abbreviations:

BHIVA, British HIV association
MDT, multi-disciplinary team
PPE, personal protective equipment
SOP, standard operating procedure
SmPC, summary of product characteristics

References:

VOCABRIA Summary of Product Characteristics. ViiV Healthcare.
REKAMBYS Summary of Product Characteristics. Janssen.
BHIVA guidelines on antiretroviral treatment for adults living with HIV-1
BHIVA guidelines for the routine investigation and monitoring of adult HIV-1-positive individuals

*The cases have been submitted by nurse practitioners in the UK who have consented and received remuneration by ViiV Healthcare to use the information. These cases were written in August 2023. All adverse events included have been reported in line with ViiV Healthcare policy.

REKAMBYS (rilpivirine long-acting injection), including the trademark is owned by the Janssen Pharmaceutical Companies and used under license by the ViiV Healthcare group of companies. All other trademarks are owned by the ViiV  Healthcare group

PM-GB-CBR-WCNT-230012 February 2024

Prescribing Information

Adverse event reporting

Adverse events should be reported. Reporting forms and information can be found at https://yellowcard.mhra.gov.uk/ or search for MHRA Yellowcard in the Google Play or Apple App store. Adverse events should also be reported to GSK via the GSK Reporting Tool or on 0800 221441.

If you are from outside the UK, you can report adverse events to GSK/ViiV by selecting your region and market, here.